Abstract
Population health focuses on the health outcomes of a defined group, including the distribution of specific outcomes within the larger group or subgroups, as well as strategies for improvement. Although applications and programs of population health have markedly grown at a time of value-based health care, the concepts of population health are still evolving and are often tied to chronic illness care. Data and measurement are critical to improving population health and there are different and often overlapping approaches. Current applications of population health management in chronic disease are grounded in care management, which seeks to extend the reach of clinical care services and enhances targeted interventions to complex patient populations across health care settings and providers. These and other population health strategies are data driven, with specific outcomes that are linked a defined population. Information technology plays a central role in population health and care management.
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References
Donabedian A. The quality of care. How can it be assessed? JAMA. 1988;260(12):1743–8.
Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380–3.
Meiris DC, Nash DB. More than just a name. Popul Health Manag. 2008;11(4):181.
Lewis N. Institute for Healthcare Improvement Leadership Blog. 2014. http://www.ihi.org/communities/blogs/_layouts/ihi/community/blog/itemview.aspx?List=81ca4a47-4ccd-4e9e-89d9-14d88ec59e8d&ID=50.
Kindig D. Health Affairs Blog. 2015. http://healthaffairs.org/blog/2015/04/06/what-are-we-talking-about-when-we-talk-about-population-health/.
What is Public Health?: CDC Foundation. https://www.cdcfoundation.org/content/what-public-health.
Stiefel M, Nolan K. A guide to measuring the triple aim: population health, experience of care, and per capita cost 2012. 2016. http://www.jvei.nl/wp-content/uploads/A-Guide-to-Measuring-the-Triple-Aim.pdf.
Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74(4):511–44.
Wagner E. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1(1):2–4.
Davy C, Bleasel J, Liu H, Tchan M, Ponniah S, Brown A. Effectiveness of Chronic Care Models: opportunities for improving healthcare practice and health outcomes: a systematic review. BMC Health Serv Res. 2015;15:194.
Improving Chronic Illness Care: About ICI and Our Work: The Robert Wood Johnson Foundation. http://www.improvingchroniccare.org/index.php?p=About_US&s=6.
Barr VJ, Robinson S, Marin-Link B, Underhill L, Dotts A, Ravensdale D, et al. The expanded Chronic Care Model: an integration of concepts and strategies from population health promotion and the Chronic Care Model. Hosp Q. 2003;7(1):73–82.
Gee PM, Greenwood DA, Paterniti D, Ward D, Miller LS. The eHealth Enhanced Chronic Care Model: a theory derivation approach. J Med Internet Res. 2015;17(4):e86.
Sidorov J, Romney M. The spectrum of care. In: Nash DB, Reifsnyder J, Fabius RJ, Pracilio VP, editors. Population health: creating a culture of wellness. 1st ed. Burlington, MA: Jones & Bartlett Learning; 2016. p. 3–22.
Burns T. Case management, care management and care programming. Br J Psychiatry. 1997;170(5):393–5.
Lewis J, Bernstock P, Bovell V, Wookey F. Implementing care management: issues in relation to the new community care. Br J Soc Work. 1997;27(1):5–24.
Patchner LS. In the belly of the beast: a case study of social work in a managed care organization. Adv Soc Work. 2002;3(1):16–32.
Rachman R. Community care: changing the role of hospital social work. Health Soc Care Community. 1995;3(3):163–72.
Case Management Society of America. Standards of Practice for Case Management. 2010. http://www.cmsa.org/portals/0/pdf/memberonly/StandardsOfPractice.pdf.
Center for Health Care Strategies I. Care Management Definition and Framework. 2007 https://www.chcs.org/media/Care_Management_Framework.pdf.
Daaleman TP, Hay, Prentice A, Gwynne M. Embedding care management in the medical home: a case study. J Prim Care Community Health. 2014;5:97–100.
S Findley et al. ugly construction to get trailing dot after citation, or after journals slug if citation is not defined J Ambul Care Manage 37 (1), 82–91. Jan-Mar 2014.
Haas SA, Swan BA. Developing the value proposition for the role of the registered nurse in care coordination and transition management in ambulatory care settings. Nurs Econ. 2014;32(2):70–9.
Hall AG, Webb FJ, Scuderi CB, Tamayo-Friedel C, Harman JS. Differences in patient ratings of medical home domains among adults with diabetes: comparisons across primary care sites. J Prim Care Community Health. 2014;5(4):247–52. https://doi.org/10.1177/2150131914538455. Epub 2014 Jun 13
Hiss RG, Armbruster BA, Gillard ML, McClure LA. Nurse care manager collaboration with community-based physicians providing diabetes care: a randomized controlled trial. Diabetes Educ. 2007;33(3):493–502.
Sepers CE Jr, Fawcett SB, Lipman R, Schultz J, Colie-Akers V, Perez A. Measuring the implementation and effects of a coordinated care model featuring diabetes self-management education within four patient-centered medical homes. Diabetes Educ. 2015;41(3):328–42.
Taliani CA, Bricker PL, Adelman AM, Cronholm PF, Gabbay RA. Implementing effective care management in the patient-centered medical home. Am J Manag Care. 2013;19(12):957–64.
Wang QC, Chawla R, Colombo CM, Snyder RL, Nigam S. Patient-centered medical home impact on health plan members with diabetes. J Public Health Manage Pract. 2014;20(5):E12–20.
Howard H, Malouin R, Callow-Rucker M. Care managers and knowledge shift in primary care patient-centered medical home transformation. Human Organization, Vol. 75. the Society for Applied Anthropology. 2016. 0018–7259/16/010010–11$1.60/1.
Ackroyd SA, Wexler DJ. Effectiveness of diabetes interventions in the patient-centered medical home. Curr Diab Rep. 2014;14:471. https://doi.org/10.1007/s11892-013-0471-z.
Thom DH, Hessler D, Willard-Grace R, Bodenheimer T, Najmabadi A, Araujo C, Chen EH. Does health coaching change patients’ trust in their primary care provider? Patient Educ Couns. 2014;96(1):135–8. https://doi.org/10.1016/j.pec.2014.03.018. Epub 2014 Apr 2
Howard HA, Malouin R, Callow-Rucker M. Care managers and knowledge shift in primary care patient-centered medical home transformation. Hum Organ. 2016;75(1):10–20.
Hines P, Mercury M. Designing the role of the embedded care manager. Prof Case Manag. 2013;18(4):182–7.
Rose SM, Hatzenbuehler S, Gilbert E, Bouchard MP, McGill D. A population health approach to clinical social work with complex patients in primary care. Health Soc Work. 2016;41(2):93–100.
Beresford P, Croft S, Adshead L. ‘We don’t see her as a social worker’: a service user case study of the importance of the social worker’s relationship and humanity. Br J Soc Work. 2008;38(7):1388–407.
Davis TS, Guada J, Reno R, Peck A, Evans S, Sigal LM, et al. Integrated and culturally relevant care: a model to prepare social workers for primary care behavioral health practice. Soc Work Health Care. 2015;54(10):909–38.
Dietrich AJ, Oxman TE, Williams JW Jr, et al. Going to scale: re-engineering systems for primary care treatment of depression. Ann Fam Med. 2004;2(4):301–4.
Holtrop JS, Potworowski G, Fitzpatrick L, Kowalk A, Green LA. Effect of care management program structure on implementation: a normalization process theory analysis. BMC Health Serv Res. 2016;16(a):386. https://doi.org/10.1186/s12913-016-1613-1.
Basics of Health IT: HeatlhIT.gov. https://www.healthit.gov/patients-families/basics-health-it.
Wu FM, Rundall TG, Shortell SM, Bloom JR. Using health information technology to manage a patient population in accountable care organizations. J Health Organ Manag. 2016;30(4):581–96.
Cusack CM, Knudson AD, Kronstadt JL, Singer RF, Brown AL. Practice-based population health: information technology to support transformation to proactive primary care. AHRQ Publication; 2010. https://pcmh.ahrq.gov/sites/default/files/attachments/Information%20Technology%20to%20Support%20Transformation%20to%20Proactive%20Primary%20Care.pdf.
Assurance NCQA. Patient-Centered Medical Home (PCMH) Recognition. http://www.ncqa.org/programs/recognition/practices/patient-centered-medical-home-pcmh.
HeatlhIT.gov. Meaningful Use Objectives and Definitions. https://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives.
Cuddeback JK, Fisher DW. Information technology. In: Nash DB, Reifsnyder J, editors. Population health: creating a culture of wellness. 1st ed. Burlington, MA: Jones & Bartlett Learning; 2016. p. 153–80.
Designing a High-Performing Health Care System for Patients with Complex Needs, The Commonwealth Fund and the London School of Economics and Political Science. 2017.
Steiner BD, Denham AC, Ashkin E, et al. Community Care of North Carolina: improving care through community health networks. Ann Fam Med. 2008;6:361–7.
Luo Z, Chen Q, Annis AM, Piatt G, Green LA, Tao M, Holtrop JS. Comparison of health plan- and provider-delivered chronic care management models on patient clinical outcomes. J Gen Intern Med. 2016;31(7):762–70. https://doi.org/10.1007/s11606-016-3617-2. Epub 2016 Mar 7
Population Health Management: Meeting the Demand for Value Based Care. https://www.ncqa.org/wp-content/uploads/2021/02/20210202_PHM_White_Paper.pdf.
Fraher E, Brandt B. Toward a system where workforce planning and interprofessional practice and education are designed around patients and populations not professions. J Interprof Care. 2019;33(4):389–97. https://doi.org/10.1080/13561820.2018.1564252. Epub 2019 Jan 23
Park B, Gold SB, Bazemore A, Liaw W. How evolving United States payment models influence primary care and its impact on the quadruple aim. J Am Board Fam Med. 2018;31(4):588–604. https://doi.org/10.3122/jabfm.2018.04.170388.
Miller BF, Ross KM, Davis MM, Melek SP, Kathol R, Gordon P. Payment reform in the patient-centered medical home: enabling and sustaining integrated behavioral health care. Am Psychol. 2017;72(1):55–68. https://doi.org/10.1037/a0040448.
Dupraz J, Le Pogam M-A, Peytremann-Bridevaux I. Early impact of the COVID-19 pandemic on in-person outpatient care utilisation: a rapid review. BMJ Open. 2022;12(3):e056086.
Amon C, King J, Colclasure J, Hodge K, DuBard CA. Leveraging Accountable Care Organization infrastructure for rapid pandemic response in independent primary care practices. Healthc (Amst). 2022;10(2):100623.
Flor LS, Friedman J, Spencer CN, Cagney J, Arrieta A, Herbert ME, et al. Quantifying the effects of the COVID-19 pandemic on gender equality on health, social, and economic indicators: a comprehensive review of data from March, 2020, to September, 2021. Lancet. 2022;399(10344):2381–97.
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Prentice, A.N., Adams, R., Porterfield, D.S., Daaleman, T.P. (2023). Population Health. In: Daaleman, T.P., Helton, M.R. (eds) Chronic Illness Care. Springer, Cham. https://doi.org/10.1007/978-3-031-29171-5_35
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