Podcast
Questions and Answers
What is the primary purpose of population health management?
What is the primary purpose of population health management?
- To analyze the financial performance of healthcare organizations
- To assess the satisfaction rate of individual patients
- To deliver personalized medicine to individuals
- To identify, reduce, or eliminate health disparities within populations (correct)
Which of the following best defines the concept of 'population health'?
Which of the following best defines the concept of 'population health'?
- The health outcomes of a group of individuals and the distribution of those outcomes within that group (correct)
- An analysis of healthcare costs in different countries
- The health outcomes of a diverse set of individuals in isolation
- The evaluation of individual health behaviors and their effects on health outcomes
Which major healthcare reform in the United States significantly advanced discussions about population health?
Which major healthcare reform in the United States significantly advanced discussions about population health?
- The Medicare Modernization Act
- The Patient Protection Act
- The Affordable Care Act (ACA) (correct)
- The Health Insurance Portability and Accountability Act (HIPAA)
Which of the following aspects is NOT explicitly considered a determinant of population health?
Which of the following aspects is NOT explicitly considered a determinant of population health?
What was one of the macro-level influences of Evans and Stoddart's population health model?
What was one of the macro-level influences of Evans and Stoddart's population health model?
What role do data analytics play in population health management?
What role do data analytics play in population health management?
How does population health address individual behavior changes?
How does population health address individual behavior changes?
Which factor is least likely to influence the design of data collection tools for population health?
Which factor is least likely to influence the design of data collection tools for population health?
What is a key difference between population medicine and population health?
What is a key difference between population medicine and population health?
Which of the following is NOT one of the three Ps associated with public health's mission?
Which of the following is NOT one of the three Ps associated with public health's mission?
Which technique is utilized in population medicine to enhance patient outcomes?
Which technique is utilized in population medicine to enhance patient outcomes?
What is a requirement for a comprehensive population health management program?
What is a requirement for a comprehensive population health management program?
How does population medicine relate to individualized and precision medicine?
How does population medicine relate to individualized and precision medicine?
What is one of the central components of the population health improvement model?
What is one of the central components of the population health improvement model?
What is the primary purpose of community engagement in population health management?
What is the primary purpose of community engagement in population health management?
Which of the following is NOT one of the health conditions targeted by the CDC 6/18 Initiative?
Which of the following is NOT one of the health conditions targeted by the CDC 6/18 Initiative?
What is a key aspect of patient involvement in the population health improvement model?
What is a key aspect of patient involvement in the population health improvement model?
What is the focus of value-based reimbursement in the context of population health management?
What is the focus of value-based reimbursement in the context of population health management?
Which intervention is part of the CDC's 6/18 Initiative aimed at health improvement?
Which intervention is part of the CDC's 6/18 Initiative aimed at health improvement?
Which of the following concepts is included as a determinant of population health?
Which of the following concepts is included as a determinant of population health?
What is the purpose of the self-management interventions in the population health improvement model?
What is the purpose of the self-management interventions in the population health improvement model?
What does the coordination and integration proposed by the Care Continuum Alliance aim to improve?
What does the coordination and integration proposed by the Care Continuum Alliance aim to improve?
Which of the following is a direct aim of the CDC's 6/18 Initiative?
Which of the following is a direct aim of the CDC's 6/18 Initiative?
Which component is highlighted in the population health improvement model as crucial for health promotion?
Which component is highlighted in the population health improvement model as crucial for health promotion?
What is a primary reason for emphasizing practitioner support through partnership in health interventions?
What is a primary reason for emphasizing practitioner support through partnership in health interventions?
Which factor is NOT recognized by CMS as relevant to population health improvement?
Which factor is NOT recognized by CMS as relevant to population health improvement?
How does value-based care reimbursement influence healthcare practices?
How does value-based care reimbursement influence healthcare practices?
Which of the following is an example of a population health measure?
Which of the following is an example of a population health measure?
What role do community health centers play in population health improvement?
What role do community health centers play in population health improvement?
What does the Triple Aim conceptual framework address in relation to population health?
What does the Triple Aim conceptual framework address in relation to population health?
What is the purpose of using informatics and analytics in healthcare interventions?
What is the purpose of using informatics and analytics in healthcare interventions?
Which statement accurately reflects the CMS suggestion for population health measures?
Which statement accurately reflects the CMS suggestion for population health measures?
Which of the following is a requirement for value-based reimbursement?
Which of the following is a requirement for value-based reimbursement?
What is one of the provisions established by the Affordable Care Act (ACA) related to population health?
What is one of the provisions established by the Affordable Care Act (ACA) related to population health?
Which of the following programs is part of the CMS value-based programs?
Which of the following programs is part of the CMS value-based programs?
What does value-based reimbursement primarily focus on?
What does value-based reimbursement primarily focus on?
What has the Center for Medicare & Medicaid Innovation done in recent years?
What has the Center for Medicare & Medicaid Innovation done in recent years?
Which of the following is NOT a provision of the ACA?
Which of the following is NOT a provision of the ACA?
Which of the following reflects a key theme of value-based reimbursement?
Which of the following reflects a key theme of value-based reimbursement?
What is one of the outcomes of the establishment of accountable care organizations (ACOs)?
What is one of the outcomes of the establishment of accountable care organizations (ACOs)?
What percentage of ACOs were in the no-risk track as of 2020?
What percentage of ACOs were in the no-risk track as of 2020?
Which of the following is NOT part of the steps a physician practice can take to prepare for value-based healthcare?
Which of the following is NOT part of the steps a physician practice can take to prepare for value-based healthcare?
What key factor is highlighted for managing high-risk populations in value-based care?
What key factor is highlighted for managing high-risk populations in value-based care?
What is the primary focus of care transitions in healthcare settings?
What is the primary focus of care transitions in healthcare settings?
Which statement is true regarding the Shared Savings Program as of January 1, 2022?
Which statement is true regarding the Shared Savings Program as of January 1, 2022?
What does CMS emphasize in its framework for value-based care?
What does CMS emphasize in its framework for value-based care?
Which of the following illustrates a challenge in care transitions?
Which of the following illustrates a challenge in care transitions?
What is the goal of alternative payment models as discussed in the content?
What is the goal of alternative payment models as discussed in the content?
Community health centers play a crucial role in population health improvement.
Community health centers play a crucial role in population health improvement.
Value-based care reimbursement models are primarily focused on reducing healthcare costs without considering patient experience.
Value-based care reimbursement models are primarily focused on reducing healthcare costs without considering patient experience.
The National Association of Community Health Centers promotes performance measurement as a population health strategy.
The National Association of Community Health Centers promotes performance measurement as a population health strategy.
Population health measures defined by CMS include the coordination of care and community services.
Population health measures defined by CMS include the coordination of care and community services.
Economic, social, and environmental factors are considered irrelevant in determining population health.
Economic, social, and environmental factors are considered irrelevant in determining population health.
Informatics and analytics are primarily used for administrative tasks rather than for targeting at-risk individuals.
Informatics and analytics are primarily used for administrative tasks rather than for targeting at-risk individuals.
Population health management focuses solely on the physical health conditions of individuals.
Population health management focuses solely on the physical health conditions of individuals.
The four features mentioned for managing older adults with chronic illnesses include monitoring to meet the patient's financial needs.
The four features mentioned for managing older adults with chronic illnesses include monitoring to meet the patient's financial needs.
Every sector, including private partners, is required for effective population health improvement.
Every sector, including private partners, is required for effective population health improvement.
Value-based reimbursement emphasizes managing patients based on the quantity of care provided.
Value-based reimbursement emphasizes managing patients based on the quantity of care provided.
The Triple Aim promotes improving patient experiences, enhancing clinical outcomes, and increasing operational costs.
The Triple Aim promotes improving patient experiences, enhancing clinical outcomes, and increasing operational costs.
According to Winslow, public health is primarily concerned with personal hygiene education.
According to Winslow, public health is primarily concerned with personal hygiene education.
High-performing organizations in population health utilize data analytics to improve patient management.
High-performing organizations in population health utilize data analytics to improve patient management.
Coordination and communication among professionals are essential for managing care transitions.
Coordination and communication among professionals are essential for managing care transitions.
The goal of population health management is to increase hospital admissions.
The goal of population health management is to increase hospital admissions.
Selection bias can be effectively minimized by utilizing an inappropriate basis for comparison.
Selection bias can be effectively minimized by utilizing an inappropriate basis for comparison.
Population health focuses primarily on individual health metrics rather than collective community conditions.
Population health focuses primarily on individual health metrics rather than collective community conditions.
The SMART criteria for goal setting includes goals that are specific, measurable, achievable, relevant, and timeless.
The SMART criteria for goal setting includes goals that are specific, measurable, achievable, relevant, and timeless.
Targeted interventions in population health management should be evidence-based and include a variety of care coordination activities.
Targeted interventions in population health management should be evidence-based and include a variety of care coordination activities.
The Quadruple Aim does not include supporting positive workforce experiences in its goals.
The Quadruple Aim does not include supporting positive workforce experiences in its goals.
The plan-do-study-act cycle is irrelevant once goals are set in the goal-setting process.
The plan-do-study-act cycle is irrelevant once goals are set in the goal-setting process.
Patient-specific care plans developed by care management teams should neglect tracking progress towards goals.
Patient-specific care plans developed by care management teams should neglect tracking progress towards goals.
Wellness and prevention programs are excluded from targeted interventions in population health management.
Wellness and prevention programs are excluded from targeted interventions in population health management.
Stakeholder obligations must align with performance measures that include regulatory requirements and accreditation standards.
Stakeholder obligations must align with performance measures that include regulatory requirements and accreditation standards.
An assets-based approach suggests that all individuals and populations have multiple weaknesses that should be improved.
An assets-based approach suggests that all individuals and populations have multiple weaknesses that should be improved.
The three-part data review process proposed by IHI begins with understanding the perspectives of the patient.
The three-part data review process proposed by IHI begins with understanding the perspectives of the patient.
Healthcare quality professionals should implement the plan-do-study-act cycle to monitor performance measures in value-based payment arrangements.
Healthcare quality professionals should implement the plan-do-study-act cycle to monitor performance measures in value-based payment arrangements.
The primary goal of population health is to improve the health of individuals exclusively rather than focusing on populations as a whole.
The primary goal of population health is to improve the health of individuals exclusively rather than focusing on populations as a whole.
A key component of the population health journey is to ignore the assets of the population.
A key component of the population health journey is to ignore the assets of the population.
Performance benchmarking is not a part of quality improvement and performance measurement as defined by the association.
Performance benchmarking is not a part of quality improvement and performance measurement as defined by the association.
Focusing solely on the needs of a population can lead to a comprehensive understanding of their strengths.
Focusing solely on the needs of a population can lead to a comprehensive understanding of their strengths.
Using data collections and analysis is unnecessary in developing effective health care delivery systems.
Using data collections and analysis is unnecessary in developing effective health care delivery systems.
The Triple Aim framework was first introduced by the Institute for Healthcare Improvement in 2008.
The Triple Aim framework was first introduced by the Institute for Healthcare Improvement in 2008.
Chronic disease prevalence remains static regardless of age demographics.
Chronic disease prevalence remains static regardless of age demographics.
Population health emphasizes volume-based reimbursement to improve healthcare quality.
Population health emphasizes volume-based reimbursement to improve healthcare quality.
In 2016, chronic disease contributed to approximately $4.1 trillion of the U.S. gross domestic product.
In 2016, chronic disease contributed to approximately $4.1 trillion of the U.S. gross domestic product.
The population of Americans aged 65 and older is expected to decline to 70 million by 2040.
The population of Americans aged 65 and older is expected to decline to 70 million by 2040.
The concept of 'joy in work' is considered a fourth aim added to the original Triple Aim framework.
The concept of 'joy in work' is considered a fourth aim added to the original Triple Aim framework.
The Care Continuum Alliance claims that patient activation is not crucial for the population health improvement model.
The Care Continuum Alliance claims that patient activation is not crucial for the population health improvement model.
Data management in population health is characterized by low volume and slow velocity.
Data management in population health is characterized by low volume and slow velocity.
The CDC's 6/18 Initiative focuses on seven health conditions to improve healthcare quality.
The CDC's 6/18 Initiative focuses on seven health conditions to improve healthcare quality.
Patients with multiple chronic conditions have decreased healthcare costs compared to those with single chronic conditions.
Patients with multiple chronic conditions have decreased healthcare costs compared to those with single chronic conditions.
Self-management interventions in the population health improvement model aim to enhance behavioral changes in individuals.
Self-management interventions in the population health improvement model aim to enhance behavioral changes in individuals.
The consolidation of population health dynamics is believed to negatively impact healthcare satisfaction.
The consolidation of population health dynamics is believed to negatively impact healthcare satisfaction.
One of the aims of the CDC's 6/18 Initiative is to improve opioid prescription practices.
One of the aims of the CDC's 6/18 Initiative is to improve opioid prescription practices.
The population health improvement model does not include evaluation of outcomes such as clinical and economic.
The population health improvement model does not include evaluation of outcomes such as clinical and economic.
The goal of primary prevention is to reduce the incidence of health problems before they occur.
The goal of primary prevention is to reduce the incidence of health problems before they occur.
The Care Continuum Alliance emphasizes only the role of specialists in health management.
The Care Continuum Alliance emphasizes only the role of specialists in health management.
Match the following care management strategies with their descriptions:
Match the following care management strategies with their descriptions:
Match the following community health concepts with their importance:
Match the following community health concepts with their importance:
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Match the following challenges in community health with their descriptions:
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Match the recommendations by NCQA for population health management with their descriptions:
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Match the following health management approaches with their definitions:
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Match the following health equity concepts with their focus areas:
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Match the foundational concepts from the Pathways to Population Health with their significance:
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Match the following aspects of patient care with their significance:
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Match the organizations involved in creating the Pathways to Population Health with their focus:
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Match the milestones from the NCQA road map to value-based care with their purpose:
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Match the following health conditions with their related management techniques:
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Match the following elements of population health with their impacts:
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Match the key components of population health management with their definitions:
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Match the terms related to value-based care with their explanations:
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Match the portfolios of population health with their specific outcomes:
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Match the following key concepts with their descriptions in population health management:
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Match the following healthcare reforms with their impacts on population health:
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Match the following components of population health management with their functions:
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Match the following population health characteristics with their descriptions:
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Match the following determinants of health with their related factors:
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Match the following elements of population health improvement model with their objectives:
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Match the conditions targeted by the CDC's 6/18 Initiative with their corresponding aims:
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Match the key aspects of the Care Continuum Alliance's population health dynamics with their implications:
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Match the following health interventions featured within the CDC's 6/18 Initiative with their target health conditions:
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Match the strategies suggested by the CDC partners with their intended outcomes:
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Match the following health management concepts with their respective focuses:
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Match the components of the population health improvement model with their functions:
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Match the following aspects of the CDC's 6/18 Initiative with their descriptions:
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Flashcards
Population Health
Population Health
The health outcomes of a group of individuals, including the distribution of those outcomes within the group.
Determinants of Health
Determinants of Health
Social, environmental, behavioral, and genetic factors that influence health.
Population Health Management
Population Health Management
The process of analyzing and managing health outcomes of a defined population.
Care Management and Transitions
Care Management and Transitions
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Data Analysis in Population Health
Data Analysis in Population Health
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Shifting Focus Beyond Episodes of Care
Shifting Focus Beyond Episodes of Care
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Social Determinants of Health Model
Social Determinants of Health Model
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Data Collection and Analytics in Population Health
Data Collection and Analytics in Population Health
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3 Ps of Public Health
3 Ps of Public Health
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Population Medicine
Population Medicine
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Data Infrastructure for Population Health
Data Infrastructure for Population Health
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Value-based Reimbursement
Value-based Reimbursement
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Community Engagement in Population Health
Community Engagement in Population Health
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Technology in Population Medicine
Technology in Population Medicine
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Decision Support in Population Medicine
Decision Support in Population Medicine
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Technology in Population Health
Technology in Population Health
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Population Health Measurement
Population Health Measurement
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Value-Based Care
Value-Based Care
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Population Health Measures
Population Health Measures
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Collaborations in Population Health
Collaborations in Population Health
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Social Determinants of Health
Social Determinants of Health
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Triple Aim
Triple Aim
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Alternative Payment Models
Alternative Payment Models
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High-Risk Populations
High-Risk Populations
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Care Transitions
Care Transitions
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Steps to Prepare for Value-Based Healthcare
Steps to Prepare for Value-Based Healthcare
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Partner for Success
Partner for Success
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Drive Appropriate Utilization
Drive Appropriate Utilization
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CMS Value-Based Programs
CMS Value-Based Programs
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The Affordable Care Act (ACA) and Population Health
The Affordable Care Act (ACA) and Population Health
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CMS Innovation Center Models
CMS Innovation Center Models
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Pay-for-Performance
Pay-for-Performance
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Comprehensive Care Management
Comprehensive Care Management
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Population Health Improvement Model
Population Health Improvement Model
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Needs Assessment in Population Health
Needs Assessment in Population Health
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Self-Management Interventions
Self-Management Interventions
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CDC's 6/18 Initiative
CDC's 6/18 Initiative
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Value-Based Care in 6/18 Initiative
Value-Based Care in 6/18 Initiative
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Cost Control in 6/18 Initiative
Cost Control in 6/18 Initiative
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Evidence-Based Interventions in 6/18 Initiative
Evidence-Based Interventions in 6/18 Initiative
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Population Health Alignment of 6/18 Initiative
Population Health Alignment of 6/18 Initiative
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Integrated Healthcare Delivery System
Integrated Healthcare Delivery System
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Chronic Disease Prevalence
Chronic Disease Prevalence
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Health Data Analytics
Health Data Analytics
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Health Data Volume and Velocity
Health Data Volume and Velocity
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Chronic Disease Economic Impact
Chronic Disease Economic Impact
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Selection Bias Minimization
Selection Bias Minimization
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SMART Goals
SMART Goals
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Quadruple Aim
Quadruple Aim
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Targeted Interventions
Targeted Interventions
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Plan-Do-Study-Act (PDSA) Cycle
Plan-Do-Study-Act (PDSA) Cycle
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Population Health Management Programs
Population Health Management Programs
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Patient-Specific Care Plans
Patient-Specific Care Plans
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Quality Improvement and Performance Measurement
Quality Improvement and Performance Measurement
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Population Health Journey
Population Health Journey
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IHI's Data Review Process
IHI's Data Review Process
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Assets-Based Approach
Assets-Based Approach
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Population Health Model
Population Health Model
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Plan-Do-Study-Act Cycle
Plan-Do-Study-Act Cycle
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Value-Based Payment Arrangements
Value-Based Payment Arrangements
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Components of the Population Health Improvement Model
Components of the Population Health Improvement Model
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Conditions Targeted by the 6/18 Initiative
Conditions Targeted by the 6/18 Initiative
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Value-Based Care Alignment in 6/18 Initiative
Value-Based Care Alignment in 6/18 Initiative
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Partnerships in the 6/18 Initiative
Partnerships in the 6/18 Initiative
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Public Health
Public Health
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Population Health Management Activities
Population Health Management Activities
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Moving Beyond Episodes of Care
Moving Beyond Episodes of Care
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Data Collection & Analytics in Population Health
Data Collection & Analytics in Population Health
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Population Health Partnerships
Population Health Partnerships
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Targeted Population Health Interventions
Targeted Population Health Interventions
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Value-Based Care Reimbursement
Value-Based Care Reimbursement
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Determinants of Population Health
Determinants of Population Health
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Triple Aim and Population Health
Triple Aim and Population Health
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Panel Management
Panel Management
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Patient Risk Stratification
Patient Risk Stratification
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Care Management
Care Management
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Complex Care Management
Complex Care Management
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Self-Management Support
Self-Management Support
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Addressing Social Determinants of Health
Addressing Social Determinants of Health
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Ensuring Health Equity
Ensuring Health Equity
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Payer Assessment
Payer Assessment
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Care Continuum Alliance's Model
Care Continuum Alliance's Model
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Patient Activation and Responsibility
Patient Activation and Responsibility
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Expanded Care Coordination
Expanded Care Coordination
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Key Components of the Population Health Improvement Model
Key Components of the Population Health Improvement Model
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AHA Population Health Framework
AHA Population Health Framework
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Care Continuum Alliance Population Health Improvement Model
Care Continuum Alliance Population Health Improvement Model
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Hospital-Community Partnerships for Population Health
Hospital-Community Partnerships for Population Health
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Community Partnerships in Population Health
Community Partnerships in Population Health
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Population Health Management (PHM)
Population Health Management (PHM)
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NCQA's PHM Recommendations
NCQA's PHM Recommendations
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Pathways to Population Health Framework
Pathways to Population Health Framework
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Four Portfolios of Population Health
Four Portfolios of Population Health
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Study Notes
Section 7: Population Health and Care Transitions
- Population health is expanding as healthcare systems transition from volume-based to value-based reimbursement models.
- This section focuses on population health and care transitions, highlighting the role of healthcare quality professionals in driving care outcomes.
- Accurate data collection tools and population-based data analysis enable stratification by risk, identification of improvement opportunities, and rapid process changes for value-based care.
- Care management and care transitions are fundamental to population health management.
Population Health
- Population health is the health outcomes of a group of individuals, including the variation of such outcomes within the group.
- Populations are often geographic (nations, communities) but can also include employees, ethnic groups, disabled persons, or prisoners.
- Population health considers medical care, social/physical environments, related services, genetics, and individual behavior as determinants of health.
- Population health's goal is to identify, reduce, or eliminate inequities and health disparities.
- This concept emerged from Canada, reflecting the influence of the social environment on health.
- It gained traction in the US with the Affordable Care Act, focusing on care beyond a single episode.
Population Health Management
- Population health management is the design, delivery, coordination, and payment of high-quality healthcare services for a population.
- It aims to achieve the Triple Aim (patient experience, population health, and reducing healthcare costs) or a potential Fourth Aim (joy in work and/or improved clinician experience).
- The Triple Aim, though introduced in 2007, adapts and evolves with changes in healthcare.
- Demographic shifts (older population, chronic conditions) and rising healthcare costs need population-based approaches.
- Data volume and velocity are high, demanding sophisticated data analysis to assess high-risk/high-volume patients and the general population.
- Organizations need to understand who the high utilizers of hospital stays or ER visits are and proactively manage them.
- Population health management considers stakeholder obligations, alignment of performance measures with accreditation standards, and, critically, the Quadruple Aim, which aims to improve care experience, population health, reduce costs, and improve staff experience.
- Value-based payment models emphasize quality, access, and outcomes over volume, requiring new skills and competencies including clinical integration, consumer/clinical/business intelligence, operational efficiency, customer engagement and efficient network development.
Data Integration
- Data integration from diverse sources (electronic health records, health information exchanges, claims data, patient monitoring devices) is crucial for population risk stratification and overall healthcare quality improvement.
- Real-time data is best.
- Data stratification should consider factors like age, race, gender, socioeconomic status, and other relevant factors.
- Predictive modeling assists in identifying high-risk situations (like readmissions) and can help mitigate risk and improve outcomes.
Goal Setting
- Goals should be SMART (Specific, Measurable, Achievable, Relevant, and Time-bound).
- Goal setting should also consider population characteristics, stakeholder obligations, clinical appropriateness, and the Quadruple Aim.
Targeted Interventions
- Interventions should be patient-centered and evidence-based, addressing care coordination and management.
- Wellness, prevention programs, and self-management tools are examples.
- Care plans focusing on prioritized patient goals are created.
- Care management teams facilitate care transitions.
- Partnerships with other organizations and tools like data sharing, training, embedding care managers, and effective communication are key for the implementation of interventions.
Measurement and Improvement
- Value-based care reimbursement models require quality measurement and focused improvement (quality, cost, and patient experience).
- Population measurements should quantify overall health and well-being (access to care, clinical outcomes, care coordination, health behaviors).
- Healthcare improvement efforts need commitment across multiple sectors, including government, tribal agencies, community service providers, and the private sector.
- Community health centers are crucial partners.
- Population health measurements often use clinical epidemiology (e.g., case-control studies, cohort studies) and other related data.
- The Centers for Medicare & Medicaid Services (CMS) suggests that a population health measure should be a broadly applicable indicator reflecting the quality of a group's overall health and well-being.
Population Health Models and Frameworks
- Population health frameworks (e.g, American Hospital Association) prioritize equitable, accountable care for populations attributed to or served by a particular healthcare system, organization, or geographic area.
- Frameworks (such as those from the Agency for Health Care Research and Quality) consider social, cultural, environmental, physical elements, and other determinants of health to drive improvement.
- Models and frameworks provide valuable structures for organizations to organize and conduct their population health efforts.
Pathways to Population Health
- Five organizations (AHA, IHI, Network for Regional Healthcare Improvement, Public Health Institute, and Stakeholder Health) collaborated to create these pathways.
- These paths aim to improve health, wellness, and equity in a population, incorporating social determinants and community partnerships.
Centers for Disease Control and Prevention (CDC) 6/18 Initiative
- This initiative focuses on improving six major health conditions (tobacco use, high blood pressure, antibiotic use, asthma, unintended pregnancies and type 2 diabetes) through interventions and resources.
- The CDC works with healthcare stakeholders to make the most impact possible.
County Health Rankings Model
- This model evaluates community health, emphasizing factors tied to social determinants.
- It considers factors like economic factors, social support, physical environment, and community quality, often measuring outcomes over time.
URAC Population Health
- URAC established standards for employer- and provider-based population health.
- The standards focus on provider and employer practices that support the population health initiatives of organizations and systems.
Care Transitions
- When patients move between care settings, effective transition management is crucial.
- Care transition efforts focus on patient safety, quality improvements, and cost-effectiveness, mitigating readmission risk for specific populations.
- Initiatives like discharge to assess (D2A) are designed to assess a patient's needs in their home post-discharge to better facilitate a seamless hand-off, often reducing length of stay and readmission rates. D2A can be applied across various specialties.
Primary Care
- Primary care case managers coordinate services for patients across various settings, addressing high-risk populations.
- A primary care emphasis on a patient-centered medical home and community-based approach supports population health management efforts.
- This approach involves engaging with patients and families, as well as other providers and community resources, to improve outcomes, coordinate care, and educate patients.
Behavioral Health Integration
- A concerted effort is increasingly being made by healthcare organizations to integrate behavioral health (mental health and substance use) into primary care; this integration is integral to comprehensive population health management.
- Comprehensive population health models consider the connection between physical health and behavioral health conditions.
Skilled Nursing and Inpatient Rehabilitation Care
- Transitioning Medicare beneficiaries to skilled nursing facilities (SNFs) or inpatient rehabilitation facilities (IRFs) after an acute care hospital stay requires clear criteria to understand patient needs and transition support.
- Case managers must understand the requirements for each facility type (as well as payer requirements). This includes specific Medicare regulations, such as the 3-day rule and/or waivers.
- CMS has accepted waivers in certain instances during the COVID-19 pandemic to broaden the scope of home-based care.
Home Healthcare
- Home healthcare is an essential part of the care continuum.
- Case managers assess post-discharge needs and connect patients with appropriate community services.
- Services are especially relevant for patients undergoing complex procedures, chronic conditions, or those with decreased mobility/cognitive function, or those preferring home-based care.
- Care management should focus on meeting patient-centered needs and preferences, especially when working with populations with complex needs.
Care Management Models and Infrastructure
- Case management models and infrastructure help to ensure smooth care transitions and coordinate comprehensive care.
- Case managers assess needs, develop plans, facilitate, coordinate, and advocate for access to resources to meet those needs.
Discharge Assessment at Home (D2A)
- The D2A initiative focuses on post-discharge assessments in a patient's home instead of the hospital; it prioritizes patient safety and continuity of care.
- It improves timely discharge, reduces the length of stay in the hospital, and reduces readmissions. This is a key aspect of improved care and is a useful model that can be applied more broadly.
Readmission Risk Mitigation
- Readmissions to the hospital after discharge or transfer present a significant cost and quality issue.
- Initiatives like STAAR (State Action on Avoidable Rehospitalizations) and other similar initiatives aim to reduce these costs and improve care transitions by better coordinating resources and care pathways, especially in acute and post-acute settings, and for high-risk patient populations.
- Care managers play a critical role in mitigating risks by thoroughly assessing individuals' needs, collaborating across care settings, and proactively identifying and addressing potential issues.
Managing Care Transitions
- Care transitions encompass the movement of patients between healthcare locations, providers, or levels of care.
- Effective coordination of information exchange, care continuity, and appropriate resources for patients undergoing transitions are crucial factors to success.
- Several problems can interfere with optimal care transitions for patients.
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Description
This quiz explores the concepts of population health and care transitions in the context of value-based healthcare systems. Discover the importance of data analysis in identifying risks and improving care outcomes. It also highlights the role of healthcare quality professionals in managing population health effectively.
