Population Health and Care Coordination

Population Health and Care Coordination 2017-06-08T20:49:08+00:00
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  • Stephen Horan, PhD is the founding president of Community Health Solutions, a Virginia firm providing research and learning support for community health improvement. He is also an Instructor for the Managerial Epidemiology course in the Virginia Commonwealth University MHSA program.  Under Steve’s leadership Community Health Solutions has helped hundreds of organizations achieve better results through effective strategy and practice. Individually, Steve has been an advisor to consumer groups, nonprofit organizations, corporations, foundations, and public sector leaders. This broad perspective informs his ability to think at the system level as well as the street level, and help people bridge gaps between policy and practice.
[/toggle][toggle title=”Learning Goals” open=”yes”]
  • Understand key elements of population health management and coordinated care.
  • Understand factors driving population health management and coordinated care in the evolving health care system.
  • Understand decision making perspectives of key stakeholders with respect to population health management and coordinated care.
[/toggle][toggle title=”What is Population Health?” open=”yes”]
  • Population health can be defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. 
  • These groups are often geographic populations, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group.
[/toggle][toggle title=”How Is Our Population Health?” open=”yes”] [/toggle][toggle title=”What Influences Population Health?” open=”yes”] [/toggle][toggle title=”What Is Population Health Management?” open=”yes”]
  • “Population health’ is descriptive, ‘population health management’ is action oriented.
  • There is no standard, widely used definition of population health management.
  • PHM is increasingly defined in terms of health information technology capabilities, but it is much more strategic than that.
  • A Working Definition: Population health management is the daily practice of optimizing health and health care relative to cost for a defined population. (Steve Horan)
  • Resources:
[/toggle][toggle title=”Who Are the Stakeholders in Population Health Management?” open=”yes”] [/toggle][toggle title=”What Are the Core Capabilities for Population Health Management?” open=”yes”]From a clinical perspective, the ability to:

  • Identify populations
  • Assess health risks
  • Define care needs
  • Optimize care models
  • Collaborate for impact
  • Assure quality
  • Demonstrate value

From a community and public health perspective, the ability to:

  • Identify at-risk populations
  • Prevent injury and disease
  • Promote healthy lifestyles
  • Develop healthy environments
  • Facilitate access to services
  • Engage community stakeholders
  • Facilitate clinical-community collaboration
  • Facilitate health-supporting policies.

From a purchaser/payer perspective, the ability to:

  • Understand health needs for defined populations
  • Promote and support health for defined populations
  • Procure services that support population health
  • Assure health value for the dollar
[/toggle][toggle title=”Case Discussion 1″ open=”yes”]
  • You are the VP for Human Resources at a manufacturing firm with 5,250 employees.
  • Your employee profile leans older (50% are age 40 to 60), and you know from experience there is a growing prevalence of high blood pressure, diabetes, respiratory disease, back pain, and depression.
  • Your CEO has just emerged from a strategy session with a look of concern.
  • Your CEO informs you that the firm is facing intensive competition for business from Europe and the Pacific Rim, and one key competitive disadvantage is your firm’s health care costs.
  • Your CEO asks you to come up with at least five ways to control health care costs for the firm and deliver these by Monday.
  • Working within your small group, adopt a population health management perspective to generate at least five ideas for your CEO.
[/toggle][toggle title=”Case Discussion 2″ open=”yes”]
  • Now that you have helped the firm develop a strategy informed by PHM, it is time for execution.
  • Your next task is to develop and RFP for one or more health plans to serve your employees and their families.
  • Working from a PHM perspective, develop at least five PHM performance indicators that a candidate health plan will have to produce in order to win a contract with your firm. 
[/toggle][toggle title=”What Is Care Coordination?” open=”yes”]
  • Care coordination is a key tactic in care management for individuals and in population health management for defined groups.
  • Care coordination can be defined as “the deliberate organization of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care services.”
  • In this definition, all providers working with a particular patient share important clinical information and have clear, shared expectations about their roles.
  • Equally important, they work together to keep patients and their families informed and to ensure that effective referrals and transitions take place.
  • Resources
[/toggle][toggle title=”What Are the Potential Benefits of Care Coordination?” open=”yes”] [/toggle][toggle title=”What Are the Key Enablers of Care Coordination?” open=”yes”]
  • Willing patients
  • Willing providers
  • Willing organizations
  • Right patient focus
  • Right care model
  • Right technology
  • Right payment model
  • Resources
[/toggle][toggle title=”Case Discussion 3″ open=”yes”]
  • Watch the video on Diana, and take notes on her health assets and challenges
  • Outline the key elements of a care coordination model for Diana
[/toggle][toggle title=”Case Discussion 4″ open=”yes”]
  • Watch the video on Keith and Allison and note the patient care challenges from both a patient and provider point of view.
  • Generate ideas for innovative payment models that could support the type of care that Keith and Allison would like to provide
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“Making the Business Case” Videos from the CDC

  1. City Planning for Healthier Communities
  2. Hispanic Communities Take Action to Improve Health
  3. Improving Health in African-American Communities
  4. Community Health Workers Bridge the Health Care Gap
  5. Culture is Prevention
  6. Community Health Investments Yield Results
  7. Community Partnerships Benefit Students, Schools, and Health
  8. Worksite Wellness Benefits Small Business
  9. Health Initiatives Boost Economic Development
  10. Healthy Options Sell in a Food Desert
  11. Hispanic Grocer Says Produce Sells
  12. Smoke Free Multi-Unit Housing
  13. Active Living in Philadelphia
  14. Healthy Snacking in Philadelphia
  15. A Grocery Store’s Healthy Options
  16. Healthy Corner Stores

REACH (Racial and Ethnic Approaches to Community Health) Videos from the CDC

  1. Community Asthma Initiative – Boston Children’s Hospital
  2. Community Diabetes Education – Medical University of South Carolina
  3. Promotion of Skim Milk in Public Schools – Institute for Urban Family Health, New York
  4. Workplace Physical Activity – UCLA Kaiser Permanente Center for Health Equity
  5. Heart Healthy – Choctaw Nation of Oklahoma
  6. Type 2 Diabetes – Schenectady County Public Health Service, NY
  7. Cancer Screening – Orange County Asian and Pacific Islander Community Alliance, Inc.
  8. Community Health Advisors and Mammography – University of Alabama at Birmingham
  9. Improving Lives, Inspiring Hope

Additional Community Prevention Videos from the CDC

  1. Obesity Prevention in San Antonio, Texas
  2. Obesity Prevention in Los Angeles County
  3. Obesity and Tobacco Prevention in the Cherokee Nation
  4. Obesity Prevention in Hamilton County, Ohio
  5. Tobacco Use Prevention in Austin/Travis County, Texas
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