Developing Community Health Practice Profiles to Map Social Determinants of Health

BACKGROUND: The University of Wisconsin-Madison Department of Family Medicine is realizing the Institute of Medicine’s vision to integrate primary care and public health by incorporating community health in its missions of patient care, education, and research. Researchers developed Community Health Practice Profiles (CHPPs) using individual-level data from billing and electronic health records combined with community-level public health data to analyze and map health conditions and identify social determinants within local communities.

METHODS: A HIPAA-compliant limited dataset was created using EHR data from UW-Health Primary Care clinics (2007-2012) for patients with known BMI in Dane County, aged 18+ (N=167,751), and diagnosed as obese (N=52,654; 31.4%). Patient-level data were geocoded by census block group, matched to community-level data, analyzed to look at the prevalence rates and associated risks, and mapped using advanced GIS techniques.

RESULTS: Risk of obesity increased based on age, gender, race, smoking, and insurance. Increased prevalence of obesity was associated with mapped Economic Hardship Index and other neighborhood factors (fruit and vegetable consumption and access). Results are being used to develop Community Health Practice Interventions with the goal of achieving the Triple Aim of improving population health, enhancing patients’ experience of care and reducing health care costs.

CONCLUSIONS: CHPPs further progress toward Health People 2020 by identifying biological and social determinants of health and helping clinicians focus on practice and neighborhood factors that contribute to disparities and impede progress in improving health outcomes. Analyses continue to inform resident and clinician training, establishment of local partnerships, and development of inteventions.