Population Health Readiness Assessment

The primary goal of this assessment is to connect users with tools and resources targeted towards their rural health organizations’ unique strengths and needs for transitioning towards population health through each milestone of Getting Motivated, Getting Informed and Getting Going. Users are encouraged to complete the assessment multiple times to monitor progress and receive updated resources to guide the journey towards population health.

Please indicate your organization's level of engagement in the critical success factors needed to transition towards population health on a scale of: High, Moderate or Low. If you have not yet started on this success factor, please indicate N/A.

Readiness Assessment

Please indicate your organization's level of engagement in LEADERSHIP activities that contribute towards population health. *

	High	Moderate	Low	N/A
I am aware of the critical role of population health in value-based reimbursement models. *	I am aware of the critical role of population health in value-based reimbursement models. - High	I am aware of the critical role of population health in value-based reimbursement models. - Moderate	I am aware of the critical role of population health in value-based reimbursement models. - Low	I am aware of the critical role of population health in value-based reimbursement models. - N/A
Board members, senior leadership, medical staff and mid-level managers understand the critical role of population health in value-based reimbursement models. *	Board members, senior leadership, medical staff and mid-level managers understand the critical role of population health in value-based reimbursement models. - High	Board members, senior leadership, medical staff and mid-level managers understand the critical role of population health in value-based reimbursement models. - Moderate	Board members, senior leadership, medical staff and mid-level managers understand the critical role of population health in value-based reimbursement models. - Low	Board members, senior leadership, medical staff and mid-level managers understand the critical role of population health in value-based reimbursement models. - N/A
The board and leadership team are focused on creating a culture change towards providing wellness care in addition to illness care. *	The board and leadership team are focused on creating a culture change towards providing wellness care in addition to illness care. - High	The board and leadership team are focused on creating a culture change towards providing wellness care in addition to illness care. - Moderate	The board and leadership team are focused on creating a culture change towards providing wellness care in addition to illness care. - Low	The board and leadership team are focused on creating a culture change towards providing wellness care in addition to illness care. - N/A

Please indicate your organization's level of engagement in STRATEGIC PLANNING activities that contribute towards population health.

	High	Moderate	Low	N/A
The board and leadership team support the organization's population health strategies.	The board and leadership team support the organization's population health strategies. - High	The board and leadership team support the organization's population health strategies. - Moderate	The board and leadership team support the organization's population health strategies. - Low	The board and leadership team support the organization's population health strategies. - N/A
The board, leadership team and medical staff can communicate the organization's vision and strategies for transitioning to population health to all staff.	The board, leadership team and medical staff can communicate the organization's vision and strategies for transitioning to population health to all staff. - High	The board, leadership team and medical staff can communicate the organization's vision and strategies for transitioning to population health to all staff. - Moderate	The board, leadership team and medical staff can communicate the organization's vision and strategies for transitioning to population health to all staff. - Low	The board, leadership team and medical staff can communicate the organization's vision and strategies for transitioning to population health to all staff. - N/A
My organization educates patients, partners and the community on the organization's vision and strategies for population health through various modes, including social media.	My organization educates patients, partners and the community on the organization's vision and strategies for population health through various modes, including social media. - High	My organization educates patients, partners and the community on the organization's vision and strategies for population health through various modes, including social media. - Moderate	My organization educates patients, partners and the community on the organization's vision and strategies for population health through various modes, including social media. - Low	My organization educates patients, partners and the community on the organization's vision and strategies for population health through various modes, including social media. - N/A

Please indicate your organization's level of engagement with activities that contribute towards the improvement of population health with PATIENTS, PARTNERS and the COMMUNITY. *

	High	Moderate	Low	N/A
My organization participates in a community health assessment process to identify health strengths and needs that best serve the people in the community. *	My organization participates in a community health assessment process to identify health strengths and needs that best serve the people in the community. - High	My organization participates in a community health assessment process to identify health strengths and needs that best serve the people in the community. - Moderate	My organization participates in a community health assessment process to identify health strengths and needs that best serve the people in the community. - Low	My organization participates in a community health assessment process to identify health strengths and needs that best serve the people in the community. - N/A
Staff receives ongoing education and support for effectively engaging multiple community stakeholders to coordinate transitions of care aimed at reducing re-admissions and improving wellness. *	Staff receives ongoing education and support for effectively engaging multiple community stakeholders to coordinate transitions of care aimed at reducing re-admissions and improving wellness. - High	Staff receives ongoing education and support for effectively engaging multiple community stakeholders to coordinate transitions of care aimed at reducing re-admissions and improving wellness. - Moderate	Staff receives ongoing education and support for effectively engaging multiple community stakeholders to coordinate transitions of care aimed at reducing re-admissions and improving wellness. - Low	Staff receives ongoing education and support for effectively engaging multiple community stakeholders to coordinate transitions of care aimed at reducing re-admissions and improving wellness. - N/A
Staff coordinates care with multiple stakeholders to address a patient's underlying needs and social determinants of health. *	Staff coordinates care with multiple stakeholders to address a patient's underlying needs and social determinants of health. - High	Staff coordinates care with multiple stakeholders to address a patient's underlying needs and social determinants of health. - Moderate	Staff coordinates care with multiple stakeholders to address a patient's underlying needs and social determinants of health. - Low	Staff coordinates care with multiple stakeholders to address a patient's underlying needs and social determinants of health. - N/A

Please indicate your organization's level of engagement for DATA COLLECTION, MANAGEMENT and ANALYSIS activities that contribute towards population health.

	High	Moderate	Low	N/A
Staff is educated on Electronic Health Record capabilities for managing population health.	Staff is educated on Electronic Health Record capabilities for managing population health. - High	Staff is educated on Electronic Health Record capabilities for managing population health. - Moderate	Staff is educated on Electronic Health Record capabilities for managing population health. - Low	Staff is educated on Electronic Health Record capabilities for managing population health. - N/A
My organization analyzes data (actuarial, clinical, HCAHPS, etc.) to improve patient care and efficiency.	My organization analyzes data (actuarial, clinical, HCAHPS, etc.) to improve patient care and efficiency. - High	My organization analyzes data (actuarial, clinical, HCAHPS, etc.) to improve patient care and efficiency. - Moderate	My organization analyzes data (actuarial, clinical, HCAHPS, etc.) to improve patient care and efficiency. - Low	My organization analyzes data (actuarial, clinical, HCAHPS, etc.) to improve patient care and efficiency. - N/A
My organization engages in an ongoing cycle of performance improvement based on data collected for improving the health and quality of care.	My organization engages in an ongoing cycle of performance improvement based on data collected for improving the health and quality of care. - High	My organization engages in an ongoing cycle of performance improvement based on data collected for improving the health and quality of care. - Moderate	My organization engages in an ongoing cycle of performance improvement based on data collected for improving the health and quality of care. - Low	My organization engages in an ongoing cycle of performance improvement based on data collected for improving the health and quality of care. - N/A

Please indicate your organization's level of engagement of OPERATIONS and PROCESSES that contribute towards population health.

	High	Moderate	Low	N/A
Staff performs operational, clinical and business processes as efficiently as possible.	Staff performs operational, clinical and business processes as efficiently as possible. - High	Staff performs operational, clinical and business processes as efficiently as possible. - Moderate	Staff performs operational, clinical and business processes as efficiently as possible. - Low	Staff performs operational, clinical and business processes as efficiently as possible. - N/A
Staff utilizes health information technology (electronic health records, health information exchanges and tele-medicine) to manage care effectively.	Staff utilizes health information technology (electronic health records, health information exchanges and tele-medicine) to manage care effectively. - High	Staff utilizes health information technology (electronic health records, health information exchanges and tele-medicine) to manage care effectively. - Moderate	Staff utilizes health information technology (electronic health records, health information exchanges and tele-medicine) to manage care effectively. - Low	Staff utilizes health information technology (electronic health records, health information exchanges and tele-medicine) to manage care effectively. - N/A
My organization operates multi-disciplinary care coordination teams that work at the top of their licenses.	My organization operates multi-disciplinary care coordination teams that work at the top of their licenses. - High	My organization operates multi-disciplinary care coordination teams that work at the top of their licenses. - Moderate	My organization operates multi-disciplinary care coordination teams that work at the top of their licenses. - Low	My organization operates multi-disciplinary care coordination teams that work at the top of their licenses. - N/A

Please indicate your organization's level of engagement of activities that contribute towards a WORKFORCE CULTURE of wellness.

	High	Moderate	Low	N/A
Board and leadership offer ongoing staff education on how to provide safe, high quality, person-centered care.	Board and leadership offer ongoing staff education on how to provide safe, high quality, person-centered care. - High	Board and leadership offer ongoing staff education on how to provide safe, high quality, person-centered care. - Moderate	Board and leadership offer ongoing staff education on how to provide safe, high quality, person-centered care. - Low	Board and leadership offer ongoing staff education on how to provide safe, high quality, person-centered care. - N/A
Board and leadership support a staff culture that is adaptable in the change towards prevention and chronic disease management.	Board and leadership support a staff culture that is adaptable in the change towards prevention and chronic disease management. - High	Board and leadership support a staff culture that is adaptable in the change towards prevention and chronic disease management. - Moderate	Board and leadership support a staff culture that is adaptable in the change towards prevention and chronic disease management. - Low	Board and leadership support a staff culture that is adaptable in the change towards prevention and chronic disease management. - N/A
Staff role models wellness.	Staff role models wellness. - High	Staff role models wellness. - Moderate	Staff role models wellness. - Low	Staff role models wellness. - N/A

Please indicate your organization's level of engagement of activities that contribute towards population health OUTCOMES and IMPACT.

	High	Moderate	Low	N/A
My organization publicly reports all quality and community health needs outcomes.	My organization publicly reports all quality and community health needs outcomes. - High	My organization publicly reports all quality and community health needs outcomes. - Moderate	My organization publicly reports all quality and community health needs outcomes. - Low	My organization publicly reports all quality and community health needs outcomes. - N/A
My organization collaborates with multiple stakeholders and payers to identify shared savings opportunities.	My organization collaborates with multiple stakeholders and payers to identify shared savings opportunities. - High	My organization collaborates with multiple stakeholders and payers to identify shared savings opportunities. - Moderate	My organization collaborates with multiple stakeholders and payers to identify shared savings opportunities. - Low	My organization collaborates with multiple stakeholders and payers to identify shared savings opportunities. - N/A
My organization participates in private payer contracts and Centers for Medicare & Medicaid Services (CMS) shared savings models.	My organization participates in private payer contracts and Centers for Medicare & Medicaid Services (CMS) shared savings models. - High	My organization participates in private payer contracts and Centers for Medicare & Medicaid Services (CMS) shared savings models. - Moderate	My organization participates in private payer contracts and Centers for Medicare & Medicaid Services (CMS) shared savings models. - Low	My organization participates in private payer contracts and Centers for Medicare & Medicaid Services (CMS) shared savings models. - N/A

Results Delivery

Please complete the following to receive assessment results and a list of tools and resources that will guide you towards population health.

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This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,560,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.

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