AcademyHealth will work with awarded CHP communities, ten Participant Communities and five Subject Matter Expert Communities, to identify data solutions, accelerate local progress, disseminate best practices and learning guides, help inform national strategy around population health challenges, and align with other delivery system reform efforts driving toward better care, smarter spending and healthier people. 

SME Communities will receive awards of $50,000 to engage in the development of topical Learning Guides designed to provide guidance, and to facilitate sharing of population health lessons.

The following five communities were announced as CHP SME Communities in January 2016: 

Essential Access Health
Essential Access Health (EAH) champions and promotes quality sexual and reproductive health care for all. EAH achieves its mission through an umbrella of services, including clinic support initiatives, advanced clinical research, provider training, patient education, advocacy and consumer awareness, and data-driven performance measurement and quality improvement. EAHwill contribute their expertise in data aggregation, technical assistance, and performance measurement and data dissemination. EAH staff is experienced in processing large quantities of data, as well as creating and maintaining data reports from different electronic health records systems. They use these data to populate web-based dashboards where participating agencies can view their performance on a core set of measures and get recommendations on possible corrective actions to improve their results. 

Greater Detroit Area Health Council
The Greater Detroit Area Health Council (GDAHC) is a not-for-profit organization that has extensive knowledge of data analysis, and performance measurement and data dissemination. GDAHC currently works as one of seven initiatives across the country focused on the use of electronic health records and supporting data to identify population-level issues, such as antibiotic use for viral infections and appropriate screening for Vitamin D deficiencies, with a goal to improve quality, health, and efficiency. They are dedicated to transparency in data sharing, and have successfully launched a system of multi-payer data measurement and public reporting of physician performance on their website ( In addition, they successfully provide aggregated individual physical level data to physician organizations to guide quality improvement. 

Minneapolis Heart Institute Foundation
The nonprofit Minneapolis Heart Institute Foundation works to improve the cardiovascular health of individuals and communities through innovative research and education, and is well-versed in cross-sector collaboration.They will share lessons learned during the development, implementation, and evaluation of Hearts Beat Back: The Heart of New Ulm Project – a 10-year community-based initiative to reduce heart attacks in New Ulm, Minnesota. They successfully collaborated with partners in various sectors to utilize data from electronic health records, community health screenings, community needs assessments, and environmental assessments to make health-conscious changes throughout New Ulm. They are committed to sharing their experiences and best practices with other communities throughout and beyond Minnesota. 

San Diego Health Connect
The San Diego Health Connect (SDHC) is a Health Information Exchange (HIE) that successfully designed and implemented a regional health information organization in the San Diego and Imperial Counties. As a part of the CHP Program, they will partner with Be There San Diego (BTSD), a multi-stakeholder collaborative experienced in improving population health with a focus on cardiovascular disease. With extensive expertise in technical infrastructure and data exchange, SDHC is an active trading partner with The Sequoia Project, a national HIE, and has partnered with San Diego County Health and Human Services to facilitate automated, electronic transmittal of relevant patient data for monitoring public health and delivering services where needed. In addition, their patient indexing system allows them to positively identify 95 percent of the region’s adult population, and their standards in naming and information records have increased patient matching to over 95 percent. BTSD, in turn, excels in sharing and comparing data in a collaborative learning environment to identify and promote best practices and improve health outcomes. 

The University of Chicago Medicine
The University of Chicago Medicine will provide expertise in data integration to the CHP Program. As the anchor health care institution on the south side of Chicago, they convened and collaborated with community partners to address critical health issues in their communities. Through their Medical Home Connection program, they leveraged partnerships with community health centers to use consistent messaging when educating emergency department utilizers on the value of using medical homes for ongoing care. Patient Advocates scheduled follow up medical home visits for patients who were discharged from the emergency room. Through an electronic portal they sent real-time information to the health centers informing them of the patients emergency room visit and follow up appointment. The program successfully increased the average show rate to follow up appointments from 35 percent to 60 percent. With the adoption of an electronic patient information portal integrated with the electronic information system, the program expanded. With the use of data from multiple sources the collaborating partners have implemented several additional population health management programs.