Community Population Health

MAHEC has a long history of developing innovative partnerships with community organizations to address social determinants of health.  The Rural Health Initiative provides MAHEC and residents increased opportunity to work with partners in rural communities to address broad patient needs.

Why address social determinants of health?  Close to 80% of health outcomes result from: health behaviors, the physical environment, and social and economic factors. Learn more from resources below (articles, videos, websites). For questions, contact

What are Social Determinants of Health?

What is ‘Upstream Medicine’?

Why Should Health Care Providers Address Social Determinants of Health?

What Are Examples of Screening Tools For SDH?

Where Can You Find WNC and NC Population Health Data?

Where Can You Find ‘Evidence-Based’ Population Health Interventions?

What are Some Frameworks / Tools to Assess and Create Regional Health Care Transformation?

What are Social Determinants of Health?

Understanding Social Determinants of Health in Healthcare Settings (Colorado Coalition for the Medically Underserved) - Video

What Are Social Determinants of Health?  (World Health Organization) - Webpage

Social Determinants of Health of Rural People (Rural Health Information Hub) - Website

Social Determinants of Health in the Healthy People 2020 Objectives & Interventions for Each Category (Office of Disease Prevention and Health Promotion) - Website

A New Way to Talk About the Social Determinants of Health (Robert Wood Johnson Foundation) - PDF document
Info about messaging to broad variety of audiences


What is ‘Upstream Medicine’?

“What makes us get sick? Look upstream.” (TED Talk) - Video
Rishi Manchanda, MD

“Moving Upstream: How Interventions that Address the Social Determinants of Health can Improve Health and Reduce Disparities” (Journal of Public Health Management and Practice) - Journal article
David Williams, PhD


Why Should Health Care Providers Address Social Determinants of Health?

“What Are Social Determinants of Health?” (Public Health Ontario) - Video
9 minute video explaining “What are Social Determinants of Health & How Do They Influence Our Health?”  Geared toward researchers in Canada, but full of relevant information for US health professionals.

Clinical Partners in Advocacy (Boston Medical Legal Partnership) - PDF document
Describes the benefits of - and how - clinical providers can help patients with: legal needs, income, housing/utilities, education, immigration status, and personal & family stability.

Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity (The Kaiser Family Foundation) - Webpage
Learn how addressing social determinants of health is important for achieving greater health equity, how to integrate SDH into health care (systems, Medicaid, health plans, etc.).

The Practical Playbook: Public Health and Primary Care Together (Duke Department of Community & Family Medicine) - Website & Book
Helping public health and primary care work together to improve population health.


What Are Examples of Screening Tools For SDH?

Patient Centered Assessment Method - Website
Patient Centered Assessment Method (PCAM) Instrument - PDF document
Free tool for primary care which inquires about a patient’s physical well-being, mental well-being, lifestyle behaviors, social environment, health literacy, etc.

National Center for Medical Legal Partnership - Webpage with links to articles and downloadable screening tools
Resources to help partners screen for legal and social needs in health care settings.

Health Begins Social and Environmental Screening Tool - PDF document
Rishi Manchanda, MD
13 Question tool for primary care to ask patients about: English language proficiency, problems getting government benefits, difficulty finding affordable/reliable childcare, housing concerns, employment, safety at home, education, etc.


Where Can You Find WNC and NC Population Health Data?

WNC Healthy Impact
A cutting edge initiative that created a standardized, regional community health assessment (CHA) process for WNC.  Find data on all WNC counties – both primary (phone/cell phone surveys) and secondary data – as well as regional and county health priorities.

Buncombe County Public Health Data and Community Health Assessment Reports
Local public health departments conduct community health assessments in NC every 3 years.  View data and reports for Buncombe County.

NC Health Information Portal (NC-HIP)
Web-based application that allows you to generate new insights from existing public and private databases.  You can geo-map data from public health data sets down to a census tract  level, plus add in your own data for visualization.

NC Behavioral Risk Factor Surveillance System (BRFSS)
Part of the CDC, this survey is conducted in all states annually.  You can find data for the WNC region on topics such as: exercise, oral health, seatbelt use, secondhand smoke, adverse childhood experiences, and immunization.

NC State Center for Health Statistics
The Center collects data, conducts health-related research, produces reports and maintains a comprehensive collection of health statistics.  Requests for specific data and analysis can be made to the Center.

County Health Rankings (University of WI)
County-level measures from a variety of national and state data sources on measures that, if improved, can help make communities healthier places to live, learn, work, and play.

Census Bureau Data on Health
Health statistics that relate to people and business in America, such as: health insurance data, fertility data, HIV/AIDs surveillance database, economic census.

National Health and Nutrition Examination Survey (NHANES)
Nationally representative survey with data sources of personal interviews, physical examinations, lab tests, nutritional assessment, and DNA repository.  Data is continuously collected, with analysis available every 2 years.


Where Can You Find ‘Evidence-Based’ Population Health Interventions?
(This can assist health providers in selecting which interventions to implement in order to improve health and social determinants of health.)

NC IMAPP  “The Healthy NC Improvement App”
Free, interactive web-based resource designed to bring together the best knowledge available in community health improvement interventions.

UNC Center for Training and Research Translation
Provides practitioners with the best available evidence and approaches related to the prevention and control of obesity.

CDC  “The Guide to Community Preventive Services”
Free resource to help you choose programs and policies to improve health and prevent disease in your community.

SAMHSA National Registry of Evidence-based Programs and Practices
Substance Abuse and Mental Health Services Administration
National registry of evidence-based programs and practices promotes the adoption of scientifically established behavioral health interventions.

Healthy People 2020 Evidence-Based Resource Tool
A searchable database with over 450 interventions categorized by strength of the evidence.

Healthy People 2020 Interventions and Resources
Search by health topic area to find Healthy People 2020: overview, objectives, data, and evidence-based resources.

Winnable Battles  - CDC
Public health priorities with large-scale impact on health and known effective strategies to address them.


What are Some Frameworks / Tools to Assess and Create Regional Health Care Transformation?

ReThink Health: Pathway for Transforming Regional Health - Website with tools and downloadable documents
This pathway is a reference for health care leaders embarking on redesigning the many sectors that contribute to healthy people and thriving communities. This tool helps you assess where your region is along the pathway, identify common pitfalls, and consider what is needed to build momentum.