National Academy of Medicine

Standardized Screening for Health-Related Social Needs in Clinical Settings: The Accountable Health Communities Screening Tool

The impacts of unmet health-related social needs, such as homelessness, inconsistent access to food, and exposure to violence on health and health care utilization, are well-established. Growing evidence indicates that addressing these and other needs can help reverse their damaging h
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Case Study: Nationwide Children’s Hospital: An Accountable Care Organization Going Upstream to Address Population Health

As managed care organizations (MCOs) and accountable care organizations (ACOs) begin to invest in population health improvement, they are faced with significant and diverse challenges. This is especially true in pediatric care; without the leverage of a national payment system and sta
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Case Study: Medicaid and Public Health Collaboration in Oregon

Oregon is one of the leading states engaged in innovative health care delivery system reform that includes population health as a central component. Collaboration among key agencies and stakeholders is an important feature of Oregon’s reform efforts, and it occurs at many levels. This
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Case Study: Improving Population and Individual Health Through Health System Transformation in Washington State

Empowered by federal, state, and community funding, Washington State has been working for years to enact delivery system transformation to improve the health and well-being of its 7 million residents. In fact, in the 1990s Washington State passed legislation offering universal coverag
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Building Health Literacy and Family Engagement in Head Start Communities: A Case Study

Policy makers, government agencies, and community organizations seeking to improve health outcomes in vulnerable populations are paying increased attention to family engagement and health literacy as key elements of a population health approach. To capitalize on the promise of prevent
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Community-Based Models of Care Delivery for People with Serious Illness

The 20th century saw remarkable improvements in life expectancy. Improvements in access to clean water, disease screening and prevention, the discovery of antibiotics and vaccines, development of organ transplantation, and advances in treatment for heart disease and cancer have all co
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Vital Directions for Health & Health Care: Priorities from a National Academy of Medicine Initiative

The United States is poised at a critical juncture in health and health care. Powerful new insights are emerging on the potential of disease and disability, but the translation of that knowledge to action is hampered by debate focused on elements of the Affordable Care Act that, while
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A Model Framework That Integrates Community and Clinical Systems for the Prevention and Management of Obesity and Other Chronic Diseases

Obesity now affects 35 percent of men, 40 percent of women, and 17 percent of 2- to 19-year-old children and adolescents in the United States. Neither clinical nor environmental changes alone are sufficient to address a problem of this magnitude. We propose here a framework that integ
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Addressing Social Determinants of Health and Health Disparities: A Vital Direction for Health and Health Care

Despite the powerful effects of social and behavioral factors on health, development, and longevity, U.S. health policy has largely ignored them. The United States spends far more money per capita on medical services than do other nations, while spending less on social services. Resid
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The Democratization of Health Care: A Vital Direction for Health and Health Care

The US health-care delivery system is in the midst of a transformation. For generations, it was rooted in a transactional, fee-for-service ethos that rewarded mainly interventions to treat individuals for diseases. Today, it aims to emphasize improvement in and maintenance of the heal
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