Skip to main content

Integration of Principles in Population Health Management

  • Chapter
  • First Online:
  • 724 Accesses

Abstract

The health-care and patient care outcomes for poly chronic conditions can be improved through the integration of multiple domains of the population health management approach and comprehensive coordination across multiple levels utilizing interdisciplinary care teams and appropriate applications of health information technology. Patient identification and risk stratification enable health-care providers to focus the appropriate resources on the patients with the greatest needs. By preventing acute events and worsening health status in higher-risk patients and providing preventative and wellness services for lower-risk patients, care management efforts can achieve optimal impact on health outcomes and cost-effectiveness. This chapter highlights the need for integrating contextual (macrolevel) and individual personalized care (microlevel) approaches to population health in solving multimorbidities.

This is a preview of subscription content, log in via an institution.

Buying options

Chapter
USD   29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD   84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD   109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD   109.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Learn about institutional subscriptions

References

  • Agency for Healthcare Research and Quality. (2014). The guide to patient and family engagement: Enhancing the quality and safety of hospital care. Rockville: AHRQ. www.ahrq.gov/research/findings/finalreports/ptfamilyscan/ptfamily1.html.

    Google Scholar 

  • Allen, A., Des Jardins, T. R., Heider, A., Kanger, C. R., Lobach, D. F., McWilliams, L., … & Sorondo, B. (2014). Making it local: Beacon communities use health information technology to optimize care management. Population Health Management, 17(3), 149–158.

    Google Scholar 

  • Care Continuum Alliance. (2012, October). Implementation and evaluation: A population health guide for primary care models. Washington, DC: Care Continuum Alliance.

    Google Scholar 

  • Center for Medicare and Medicaid Services. Quality payment program. Accessed from https://qpp.cms.gov/ on 1 Apr 2017.

  • Clarke, J. L., Bourn, S., Skoufalos, A., Beck, E. H., & Castillo, D. J. (2016). An innovative approach to health care delivery for patients with chronic conditions. Population Health Management, 20(1), 23–30.

    Article  Google Scholar 

  • Cromley, E. K., Wilson-Genderson, M., Heid, A. R., & Pruchno, R. A. (2016). Spatial associations of multiple chronic conditions among older adults. Journal of Applied Gerontology, 1–25. https://doi.org/10.1177/0733464816672044.

  • Healthcare Informatics. (2016, June). A roadmap for population health management. https://www.pcpcc.org/sites/default/files/resources/PHM-IBM_Watson-RR.pdf. Accessed 20 Mar 2017.

  • Jackson, C., Kasper, E. W., Williams, C., & DuBard, C. A. (2016). Incremental benefit of a home visit following discharge for patients with multiple chronic conditions receiving transitional care. Population Health Management, 19(3), 163–170.

    Article  Google Scholar 

  • Janosky, J. E., Armoutliev, E. M., Benipal, A., Kingsbury, D., Teller, J. L., Snyder, K. L., & Riley, P. (2013). Coalitions for impacting the health of a community: The Summit County, Ohio, experience. Population Health Management, 16(4), 246–254.

    Article  Google Scholar 

  • Kronick, R. G., Bella, M., Gilmer, T. P., & Somers, S. A. (2007). The faces of Medicaid II: Recognizing the care needs of people with multiple chronic conditions. Hamilton: Center for Health Care Strategies, Inc.

    Google Scholar 

  • Kronick, R. G., Bella, M., & Gilmer, T. P. (2009). The faces of Medicaid III: Refining the portrait of people with multiple chronic conditions. Hamilton: Center for Health Care Strategies, Inc.

    Google Scholar 

  • Lochner, K. A., & Cox, C. S. (2013). Prevalence of multiple chronic conditions among medicare beneficiaries, United States, 2010. Preventing Chronic Disease, 10, 120–137.

    Article  Google Scholar 

  • Lochner, K. A., Goodman, R. A., Posner, S., & Parekh, A. (2013). Multiple chronic conditions among medicare beneficiaries: State-level variations in prevalence, utilization, and cost, 2011. Medicare & Medicaid Research Review, 3(3), E1–E19.

    Article  Google Scholar 

  • McDonald, K. M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., Smith-Spangler, C., Brustrom, J., Malcolm, E., Rohn, L., & Davies, S. (2014, June). Care coordination atlas version 4 (Prepared by Stanford University under subcontract to American Institutes for Research on Contract No. HHSA290-2010-00005I). AHRQ Publication No. 14–0037- EF. Rockville: Agency for Healthcare Research and Quality.

    Google Scholar 

  • Miller, A., Cunningham, M., & Ali, N. (2013). Bending the cost curve and improving quality of care in America’s poorest city. Population Health Management, 16(S1), S–17.

    Article  Google Scholar 

  • Proctor, J., Rosenfeld, B. A., & Sweeney, L. (2016, January). Implementing a successful population health management program (Rep.). Retrieved March 20, 2017, from Philips website: https://www.usa.philips.com/c-dam/b2bhc/us/Specialties/community-hospitals/Population-Health-White-Paper-Philips-Format.pdf

  • Rocca, W. A., Boyd, C. M., Grossardt, B. R., Bobo, W. V., Rutten, L. J. F., Roger, V. L., … & Sauver, J. L. S. (2014, October). Prevalence of multimorbidity in a geographically defined American population: Patterns by age, sex, and race/ethnicity. In Mayo Clinic Proceedings, 89(10), 1336–1349. Elsevier.

    Google Scholar 

  • Sears, M. E., & Genuis, S. J. (2012). Environmental determinants of chronic disease and medical approaches: Recognition, avoidance, supportive therapy, and detoxification. Journal of Environmental and Public Health, 2012, 1–15.

    Google Scholar 

  • Stoto, M. A. (2013). Population health in the Affordable Care Act era (Vol. 1). Washington, DC: AcademyHealth.

    Google Scholar 

  • Suter, P., Suter, W. N., & Johnston, D. (2011). Theory-based telehealth and patient empowerment. Population Health Management, 14(2), 87–92.

    Article  Google Scholar 

  • Tinetti, M. E., Esterson, J., Ferris, R., Posner, P., & Blaum, C. S. (2016). Patient priority-directed decision making and care for older adults with multiple chronic conditions. Clinics in Geriatric Medicine, 32, 261–275.

    Article  Google Scholar 

  • To, T., et al. (2015). Health risk of air pollution on people living with major chronic diseases: A Canadian population-based study. British Medical Journal, 5, 1–8.

    Google Scholar 

  • U.S. Department of Health and Human Services. (2010). Multiple chronic conditions—A strategic framework: Optimum health and quality of life for individuals with multiple chronic conditions. Washington, DC: U.S. Dept. of Health and Human Services.

    Google Scholar 

  • Wan, T. T. H. (2002). Evidence-based health management: Multivariate modeling approaches. Boston: Kluwer Academic Publishers.

    Book  Google Scholar 

  • Wan, T. T. H. (2014). A transdisciplinary approach to health policy research and evaluation. International Journal of Public Policy, 10(4–5), 161–177.

    Article  Google Scholar 

  • Ward, B. W. (2017). Barriers to health care for adults with multiple chronic conditions: United States, 2012–2015 (NCHS data brief, no 275). Hyattsville: National Center for Health Statistics.

    Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Cite this chapter

Wan, T.T.H. (2018). Integration of Principles in Population Health Management. In: Population Health Management for Poly Chronic Conditions. Springer, Cham. https://doi.org/10.1007/978-3-319-68056-9_3

Download citation

Publish with us

Policies and ethics