Table 2.

Additional case studies: PETAL framework

Program	Target Population	Summary of Program
Camden Coalition of Healthcare Providers: Care Management Initiatives, Healthcare HotSpotting	Frequent users/patients with high admission rates	Health care Hotspotting (HH) uses health care data driven to better serve the needs of patients with high readmission rates, or “Super Users.” The HH technique applies a multidisciplinary and coordinated approach that not only treats the patient's health needs but also addresses SDH.a
Bithlo Transformation Effort	Semirural, impoverished, environmental health hazards	The “Bithlo transformation Effort,” focuses on improving the health of the community using the following core components: education, environment, transportation, health care, housing, basic needs, and building community. The Florida Hospital along with 65 community, health, and political partners work together to improve the health of the region. The effort uses health data gathered from Florida Hospital/Adventist Health System's EHR records to measure the impact of their engagements.b
Dignity Health	Impoverished and disenfranchised	Dignity Health partners with their community members to improve the quality of life of their patients through health programs, grants, investments, and sustainability initiatives. Hospitals affiliated with Dignity Health participate in an annual report on the measurable impacts of their community health programs to adjust for gaps and improvements. Dignity Health, along with Truven Health, jointly developed a Community Need Index (“CNI”). The CNI uses data to analyze demographic metrics and SDH (for example, income, culture/language, education, insurance, and housing) to inform investment strategies addressing the drivers of health inequities.b , c
New Hampshire Health and Equity Partnerships	Racial, ethnic, and linguistic minorities	Comprehensive public/private program that focuses on addressing SDH. Periodic report cards are released that report a “disparity score” that includes information pertaining to race, ethnicity, and language (REaL). REaL data are then used to compare outcomes across populations to better address health inequities.d , e

^aCamden Coalition of Health Providers. https://www.camdenhealth.org/. Last visited April 20, 2017.

^bStakeholder Health. https://stakeholderhealth.org/about/. Last visited April 17, 2017.

^cCommunity Need Index Methodology and Source Notes. Truven Health Analytics. http://cni.chw‐interactive.org/Truven%20Health_2015%20Source%20Notes_Community%20Need%20Index.pdf .

^dPooler, Jennifer. Holly Korda, Plan to Address Health Disparities and Promote Health Equity in New Hampshire. New Hampshire Health and Equity Partnership. Altarum Institute. March 2011.

^eBuilding a Nation of Neighbors. Stories of Impact: Pursuing Health Equity through Welcoming Work. Welcoming America. http://www.welcomingamerica.org/sites/default/files/Health%20Equity%20Stories%20of%20Impact%20FINAL.pdf. Last visited April 17, 2017.