Population Health

The Montana Primary Care Association’s population health programs are focused on improving the overall health and well-being of health center patients.

Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” [1] Population health efforts may target the entire patient population served at health centers or target defined sub-populations of patients with similar needs.

Population health lowers the total cost of care and enhances the wellbeing of the patients served. Thus, a population health model of care is key to health center success in value-based and alternative payment models.

Stay in the loop – sign up for the MPCA Population Health Bulletin email list here. MPCA sends out a quarterly bulletin with updates, resources, and training opportunities.

[1] (Kindig D, Stoddart G. “What is population health?” American Journal of Public Health. 2003. 93(3):380-383).

MPCA’s population health projects include:

Cover Montana and Cover Native Montana

Cover Montana works to connect Montanans who have questions about enrolling in health insurance options with a local enrollment assister who can walk them through the process. Enrollment assisters are located at Health Centers, Urban Indian Organizations, hospitals, Indian Health Service, Tribal Health, and through Cover Montana’s Navigator team.

In August of 2024, MPCA was awarded a federal Navigator grant to provide statewide outreach and enrollment assistance. In addition, MPCA provides training and technical assistance to enrollment assisters from across Montana. Trainings are done via webinar and MPCA’s fall summit that happens in October. Stay in the loop, sign up for the Cover Montana email list.

Complex Social Needs and Enabling Services Interventions

Clinical care alone cannot improve the health and well-being of health center patients and Montana communities. MPCA supports health centers in screening for individual patient social needs. Many Montana health centers are utilizing the PRAPARE screening tool. There are also many national partners focused on social needs screening and they regularly host learning collaboratives and learning opportunities including:

PRAPARE Tiger Team Meetings – A workgroup for all-things social needs, focusing on providing feedback to improve the functionality of the PRAPARE Template in EHR systems.
The Health Center Resource Clearinghouse – HRSA’s National Resource Center (NRC) for Training and Technical Assistance (TTA) advances health center operational excellence through the development, coordination, and dissemination of training and technical assistance available to health centers nationwide.

MPCA is also working to support centers in tracking the enabling services interventions they provide in an effort to address non-clinical social needs. This work is done in coordination with the Montana HCCN and through the Azara DRVS tool to ensure Montana is building the data infrastructure to understand and effectively impact the health and well-being of health center patients now and in the future.

The Quality Data Initiative (QDI)

5,117 or 4.64% of Montana health center patients are Veterans, compared to 1.36% of all health center patients. Montana has historically had the highest rate of uninsured Veterans in the US and continues to have the highest rate of suicide among Veterans in any state.Uniform Data System, Health Center Program Grantee Data, Montana, 2018

Health centers must understand and work to impact both the clinical and non-clinical needs of patients in order to impact health outcomes. MPCA’s population health efforts are often done in partnership with the Quality Data Initiative. In 2020, QDI began collecting and reporting out demographic for patients who are veterans and patients who are experiencing homelessness.

Cover Montana Summit