Pop Health Final Exam PDF

Introduction & Defining Population Health What is Population Health & how is it different from other definitions of health? § Population Health is defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" (Kindig & S...

Introduction & Defining Population Health What is Population Health & how is it different from other definitions of health? § Population Health is defined as "the health outcomes of a group of individuals, including the distribution of such outcomes within the group" (Kindig & Stoddart, 2003). It emphasizes health outcomes as a result of interactions with healthcare systems and incorporates a continuum-of-care approach. § Difference from other definitions: Unlike public, community, or global health, population health focuses on health outcomes and their distribution within a group, integrating health service delivery, prevention, and promotion strategies. Public health focuses on organized community efforts, and global health emphasizes transnational health efforts. What are the primary foci of Population Health? § Comprehensive health service delivery across the continuum of care. § Health promotion and prevention strategies. § Addressing health outcomes as derivatives of healthcare interactions. § Focusing on social determinants of health (SDOH) and factors like environmental, socioeconomic, and behavioral influences. What is the business case for Population Health? § 80% of Health Outcomes are due to SDOH § We spend 88% of our money on medical services What is Population Health Management? § Concerned with who, where, & when health services are provided, the appropriate cost of the service, & population health outcomes § Provides the necessary operational expertise to ensure desired outcomes of a specific population § Gathering & analyzing data on populations to develop approaches to foster health & quality of care improvements while managing costs § Process of improving clinical health outcomes of a defined group of individuals through improved care coordination & patient engagement supported by appropriate financial & care models How has Population Health evolved as a concept over time? § § ACA of 2010 served as a catalyst for change moving towards population health focus by asking the question, how do we strive to get more people access to healthcare?  § However, had no definitive strategy or framework for achieving these goals. § Experts began to ID frameworks & approaches for implementing population health. Understand how to apply the PHM Framework to guide your action as a population health manager § PHM: Strives to address health needs at all points along the continuum of health & well-being through participation of, engagement with, & targeted interventions for the population § The Population Health Conceptual Framework identifies the general components and stakeholders of population health. It first depicts the identification, assessment and stratification of program participations. The core of the model includes the continuum of care, as well as patient-centered interventions. The patient (consumer) is central in the model and is surrounded by various overlapping sources of influence on the management of his or her health. This can include, but is not limited to, organizational interventions, tailored interventions and family and community resources. Operational measures are represented under program outcomes. Finally, the cycle of program improvement based on process learnings and outcomes is prominently depicted by the large curved green arrows. § Goal: maintain or improve the physical & psychosocial wellbeing of individual through cost-effective & tailored health solutions Assessment: know your population Stratification: ID risk level Person-Centered Intervention: align pt needs using available resources & tailored plans Impact Evaluation: assess health status, effectiveness & efficiency  Social Determinants of Health Pt. 1 What are social determinants of health? § Conditions in which people are born, grow, work, live, & age, & the wider set of forces & systems shaping the conditions of daily life. What did the Camden Coalition highlight about population health? § The Camden Coalition showed that a small percentage of individuals can drive a significant portion of healthcare costs due to unmet social and economic needs. By addressing these underlying factors (e.g., poverty, housing insecurity, addiction), care costs can be reduced, and patient outcomes improved. Describe social conditions as Fundamental Causes of Disease (Link & Phelan reading) § Social conditions such as socioeconomic status, power, and resource access are fundamental causes of disease. They shape individuals' ability to utilize health advancements, perpetuating health disparities regardless of shifting risk factors. § This focus on proximate risk factors, potentially controllable at the individual level, resonates with the values and belief systems of Western culture that emphasize both the ability of the individual to control his or her personal fate and the importance of doing so. § Paper argues that medical researchers have traditionally focused on proximate risk factors (e.g. weight, smoking status, exercise) to disease outcomes and policies to reduce these risks § Social conditions as factors that involve a person’s relationships to other people, including positions occupied within the social and economic structures of society. § Social status is a fundamental influence on health because, regardless of risks, people with more resources, information, power, and useful networks are better able to take advantage of what is known about preventing disease and maintaining health What is the call for policymakers in considering social conditions as cause of disease? § Require that any effort to reduce individual risk (for example, through health interventions or educational programs) should also include an analysis of the broader factors or conditions that lead people to become vulnerable in the first place. § Consider whether a proposed intervention will have an impact on one disease, or whether it has an influence on a fundamental cause and will affect multiple diseases. § Be skeptical about interventions that focus only on intervening variables but claim to address the broader social condition. What are the 5 SDOH domains? How do SDOH relate to physical health? § Economic Stability: Impacts access to nutritious food, safe housing, and healthcare. § Education Access & Quality: Influences health literacy and employment opportunities. § Healthcare Access & Quality: Directly affects timely treatment and preventive care. § Neighborhood & Built Environment: Shapes exposure to pollutants, safety, and recreational opportunities. § Social & Community Context: Affects mental and physical health through social support and stress levels.  Value Based Care How have we progressed from a Fee for Service to Value Based Care Model of reimbursement for care? § The transition began as FFS, which incentivized volume over quality, led to high healthcare costs and uneven outcomes. VBC emerged to prioritize quality and cost-effectiveness by aligning incentives for providers to achieve better health outcomes. Why has this change occurred? § Rising healthcare costs and unsustainable expenditures. § Recognition that FFS encourages unnecessary procedures without guaranteeing quality. § Policymaker and payer demand for improved health outcomes and cost control. Where do we currently see Value Based Payment models implemented? § MA capitation arrangements, Primary Care Practice ACOs, Managed Medicaid Why are these models in theory more effective (think about incentives)? What makes them challenging to implement? § Alignment of Incentives: Incentives Alignment: Providers are rewarded for outcomes, not volume. Patient-Centered: Emphasizes care coordination and prevention. Cost-Effective: Encourages efficient resource use and avoids unnecessary procedures. § Challenges Requires robust IT systems and data sharing. High initial investment in care coordination infrastructure. Need for provider and patient engagement in evidence-based care. Complexities in scaling across diverse payer mixes. Does Value Based Care work? § Evidence shows that VBC improves outcomes and reduces costs in certain contexts (e.g., Medicare Advantage, ACOs). However, challenges in scalability, equity, and consistent implementation persist. Success depends on deep provider engagement and robust infrastructure.  Social Determinants of Health Pt. 2 What are the challenges to Value Based Care models? § Lack of Infrastructure: Insufficient technology and data-sharing systems. § Capital Shortages: Limited financial resources for initial implementation. § Complex Healthcare Systems: Difficulty coordinating care and aligning incentives. § Redistribution of Revenue: Financial shifts may benefit some providers but harm others. § Resistance to Change: Challenges in reducing hospital capacity and reallocating resources. Describe & utilize the VBC Framework from Teisberg et al. 2020 reading § Capability: Helping patients achieve their health goals. § Comfort: Reducing pain and discomfort. § Calm: Providing peace of mind through coordinated care. The framework emphasizes aligning care delivery with patient experiences and outcomes through tailored, patient-focused interventions. Describe the difference between Upstream, Midstream, and Downstream components of the medical progression of disease & intervention § Upstream Issues. Addressing SDOH. In the case of the parable, this would include installing the barrier. In general, this would refer to improving education systems, housing, and economic opportunities. § Midstream. In the case of the parable, this would refer to educating individuals to improve their swimming ability or how to navigate the bridge without falling. In general, this would include factors related to individual-level behavior change such as promoting healthy eating, healthy family relationships, and exercise. § Downstream. In the case of the parable, this would include costs of treating near- drowning and expenses related to the rescue. In general, this would include treatment of chronic and relapsing conditions such as diabetes and related complications including dialysis or treatment for diabetic retinopathy. How do we best implement SDOH into practice? § Data Integration: Use EHRs to capture and analyze SDOH indicators (e.g., PRAPARE, ICD-10 Z-codes). § Community Partnerships: Collaborate with local organizations addressing food security, housing, and employment. § Tailored Interventions: Provide targeted resources based on individual needs.  § Policy Alignment: Advocate for Medicaid or CMS programs that incentivize addressing SDOH. What are ethical considerations to implementing SDOHs into practice? § Equity: Ensure that interventions reduce disparities rather than exacerbate them. § Confidentiality: Protect patient data when sharing with community partners. § Resource Allocation: Avoid bias in prioritizing SDOH interventions. § Accountability: Ensure that collected SDOH data leads to meaningful action.  Population Health Models Pt. 1 Describe the premises of population health § Population health aims to improve care coordination, enhance quality, and reduce costs by identifying and addressing the needs of specific populations. This involves segmenting and stratifying populations through predictive modeling, addressing chronic health conditions and social determinants of health (SDOH), and implementing targeted interventions. There is no universal approach; instead, multiple models are adapted to meet specific needs. How was the Triple Aim & the ACA an instigator of implementing population health in practice? § Triple Aim: Introduced the goals of improving population health, enhancing patient experience, and reducing costs. It emphasized the need for "integrators" to coordinate care across health, public health, and social service organizations. § ACA (Affordable Care Act): Established financial incentives for value-based care models, such as Accountable Care Organizations (ACOs) and penalties for hospital readmissions. It encouraged population health approaches through quality benchmarks and alternative payment methods. What are the most popular alternative delivery models for value-based payment options? § Integrated Delivery Networks (IDNs): Comprehensive systems integrating hospitals, primary care, and specialty care to streamline patient experiences and cost management. § Accountable Care Organizations (ACOs): Groups of providers accountable for the total cost and quality of care for a defined population. § Patient-Centered Medical Homes (PCMHs): Primary care-focused models providing coordinated, patient-centric care, especially for chronic conditions. Describe integrated delivery networks, accountable care organizations, and patient centered medical homes. How are they similar? How do they differ? What are benefits and challenges to each? How does each implement a population health approach in care delivery? § Integrated Delivery Networks (IDNs): Definition: Groups of organizations or single entities working together to provide coordinated, holistic care for a population. Structure: Includes horizontal integration (similar services under one brand) and vertical integration (different levels of care, e.g., primary, secondary, and tertiary). Benefits: Streamlined care, reduced duplication, and improved coordination. Challenges: Complexity, high costs, and management issues. § Accountable Care Organizations (ACOs): Definition: Networks of providers accountable for the total cost and quality of care for a defined population.  Payment Model: Incentives tied to achieving quality benchmarks and cost savings. Benefits: Improved care coordination, reduced duplication, and focus on preventative care. Challenges: Difficulties in managing shared risks and sustaining financial savings across the network. § Patient-Centered Medical Homes (PCMHs): § Definition: Primary care-focused models offering coordinated, patient- centered care, particularly for chronic conditions. § Attributes: Emphasis on patient engagement, team-based care, and proactive management. § Benefits: Enhanced outcomes for chronic conditions and reduced care fragmentation. § Challenges: High initial investments and need for adherence to quality protocols. § Similarities Across Models: § Emphasis on care coordination and improved patient outcomes. § Use of data-driven decision-making and technology like electronic health records (EHRs). § Focus on prevention and addressing chronic disease management. § Differences Across Models: § IDNs: Operate on a larger scale with broad integration across care levels. § ACOs: Focus on cost savings and shared financial risks among providers. § PCMHs: Concentrate on individual practices and proactive, patient- centered care. § Population Health Approach in Care Delivery: § IDNs: Holistic, system-wide integration to serve community needs. § ACOs: Foster cost efficiency and quality improvement for defined populations. § PCMHs: Provide personalized, team-based care for patients with chronic diseases.  Health Needs Assessment & Outcomes What is community benefit, who must fulfill community benefit, & why? § What is Community Benefit? Programs or activities addressing community needs to improve access, population health, and provide treatment. These efforts are not for marketing purposes. § Who Must Fulfill It and Why? Non-profit hospitals are required by the IRS to conduct and act on Community Health Needs Assessments (CHNAs) every three years to maintain tax-exempt status under the Community Benefit Standard. This ensures hospitals justify their federal funding and tax advantages. Describe the varying components to a community health needs assessment. § Understanding Community Health Needs: Evaluate health conditions, behaviors, and mortality/morbidity rates using data. § Stakeholder Collaboration: Work with public health agencies, community leaders, and organizations. § Data Collection and Analysis: Focus on population health rather than individual patient needs. § Implementation Strategy Development: Create a detailed plan to address identified priorities. § Transparency and Accessibility: Publish findings and plans for public access. What is the relationship between a CHIP & a CHNA? § CHNA: Identifies community health needs through assessment and prioritization. § CHIP (Community Health Improvement Plan): Develops and executes strategies to address the needs identified in the CHNA. § Together, CHNAs and CHIPs ensure a cycle of assessment, strategy implementation, and evaluation for community health improvements. What does a CHNA accomplish in the end? § Identifies and prioritizes health needs for a specific community. § Focuses on improving community-level health through SDOH and data-driven approaches. § Develops actionable, strategic plans to address prioritized health concerns. § Enhances transparency and accountability for non-profit hospitals through required public reporting.  Population Health Decision Making What are questions that should be considered in population health decision- making? § Which metrics will you use to identify your population at risk? § How will you stratify your papulation at risk by level of risk? § What types of interventions will you use? § Who will implement these interventions? § What outcomes will you expect and how will you measure? What is risk vs risk segmentation vs stratification vs risk management? § Risk: The probability an event will occur § Risk Segmentation: The act of dividing patients into categories of risk based on their clinical and lifestyle characteristics § Risk Stratification: systematic process for identifying and predicting patient’s risk levels relating to healthcare needs, services, and care coordination with the goal of identifying those at highest risk and managing their care to prevent poor health outcomes § Risk Management: developing and implementing safe and effective patient care practices and pathways, monitoring financial costs, and maintaining safe working environments to ensure optimum health outcomes. What is the step-by-step process for risk segmentation & stratification that population health managers should follow? § Define the Population: Use data (e.g., CHNA, SDOH indicators, EMR data) to identify the population at risk. § Identify Risk Factors: Determine specific clinical, lifestyle, and utilization factors influencing risk. § Segment the Population: Divide the population into categories based on current and prospective health data. § Stratify by Risk Level: Assign individuals to risk tiers (e.g., low, medium, high). § Design Interventions: Align interventions with each risk level, considering care needs and cost implications. § Implement Risk-Based Care Plans: Assign appropriate providers, channels, and timelines for interventions. § Evaluate Outcomes: Use metrics to monitor the success of interventions and refine strategies.  How do you implement this process? § Define the Population: Use data (e.g., CHNA, SDOH indicators, EMR data) to identify the population at risk. § Identify Risk Factors: Determine specific clinical, lifestyle, and utilization factors influencing risk. § Segment the Population: Divide the population into categories based on current and prospective health data. § Stratify by Risk Level: Assign individuals to risk tiers (e.g., low, medium, high). § Design Interventions: Align interventions with each risk level, considering care needs and cost implications. § Implement Risk-Based Care Plans: Assign appropriate providers, channels, and timelines for interventions. § Evaluate Outcomes: Use metrics to monitor the success of interventions and refine strategies.  Pop Health Models, Measuring Outcomes, & Co-creation for the Future What are emerging population models of health? § Patient-Centric Models: Focus on individual needs and experiences. § Chronic Care Models: Address long-term management of chronic diseases. § Telehealth & Remote Monitoring: Utilize technology to expand access and continuity of care. § Wearable Devices: Encourage proactive health monitoring. § Post-Acute Care Innovations: Improve care transitions and reduce readmissions. § Health Behavior Change Models: Incorporate strategies to promote healthier lifestyles and behavior What does this new era of healthcare call for? Patient-Centricity: Personalizing care for better outcomes and satisfaction. Coordinated Care: Ensuring seamless transitions across care levels. Strategic Focus on Chronic Conditions: Addressing the high cost and prevalence of chronic diseases. Technology Integration: Leveraging tools like telehealth and wearable devices. Health Behavior Engagement: Encouraging active participation in managing health. How does chronic disease impact our current population? Prevalence: 1 in 2 Americans will develop a chronic disease during their lifetime. Cost: Chronic and mental health conditions account for 90% of healthcare expenditures. Outcomes: Gaps in care transitions lead to increased hospital readmissions and preventable complications. How could we best intervene? Coordinated Care: Ensure linkages across primary, acute, and post-acute settings. Self-Management Education Programs: Empower patients to manage symptoms and reduce unnecessary visits. Transitions of Care Models: Use frameworks like Coleman’s Four Pillars to improve care workflows. Behavioral Interventions: Target lifestyle changes using evidence-based models. Post-Acute Care Strategies: Expand services like hospital-at-home programs. How can you as a population health manager use the Health Belief Model & the Transtheoretical Model of Behavior Change? § Health Belief Model (HBM):  Perceived Susceptibility: Assess how vulnerable the population feels to a condition. Perceived Severity: Emphasize the consequences of inaction. Perceived Benefits: Highlight tangible outcomes of behavior changes. Perceived Barriers: Address obstacles to engagement and provide solutions. Cues to Action: Use reminders, media, and community campaigns to trigger actions. Self-Efficacy: Empower individuals to feel capable of making changes through training and support. § Transtheoretical Model (TTM): Precontemplation: Raise awareness about the need for change. Contemplation: Provide information to encourage decision-making. Preparation: Offer resources and support for planning. Action: Facilitate access to interventions and monitor progress. Maintenance: Encourage continued adherence and prevent relapse through ongoing support and reinforcement. By applying these models, population health managers can create tailored strategies that address both individual and community health needs effectively.  Population Health Hot Topics How could we intervene to decrease the downstream impacts of the global disease burden in LMIC of musculoskeletal trauma? § Prevention: Strengthen road safety measures, workplace safety education, and public awareness campaigns. § Healthcare Infrastructure: Improve access to affordable diagnostic and treatment services, expand training for local orthopedic specialists, and enhance healthcare navigation systems. § Post-Injury Care: Develop rehabilitation programs and cost-effective follow-up protocols for long-term recovery. § Policy and Research: Use local data to inform policies, advocate for prioritizing trauma care, and align efforts with national strategic health plans. What are the myriad impacts that musculoskeletal trauma has on the fabric of a society? § Economic losses from reduced productivity and household income. § Increased healthcare costs and strain on health systems. § Long-term disability affecting community cohesion and social support structures. How has mental health care evolved? § The transition from asylums to community mental health care with deinstitutionalization. § Emphasis on holistic biopsychosocial models of care. § Challenges like lack of infrastructure and addressing co-occurring conditions. What are calls to action regarding mental health intervention from a population health standpoint today? § Focus on prevention through upstream interventions addressing social determinants of health. § Enhance community-based care and integrate mental health into primary care. § Build partnerships with policymakers, community organizations, and healthcare providers to reduce barriers to care.