NURS 4010 – Family, Community, and Population-Based Care Research Paper

NURS 4010 – Family, Community, and Population-Based Care Research Paper

NURS 4010 – Family, Community, and Population-Based Care Research Paper

Patient-Centered Health Advisory Council Iowa Department of Public Health JULY2016Population-Based Healthcare is focused on the system established to improve the health outcomes of a group of individuals, including distribution of such outcomes within the group. To move toward this type of care, new payment models are emerging that encourages the integration of community services offered outside of the traditional healthcare provider model and allows for the creation of sustainable infrastructures that will hold this expanded healthcare system accountable for both the cost and quality of care.NURS 4010 – Family, Community, and Population-Based Care Research Paper Healthcare in the U.S. is transitioning away from the traditional fee-for-service model, where healthcare providers are paid for each service they provide, such as an office visit, test, or procedure. New payment models are being used that are designed to reward the healthcare system for improvements in population health status. Population-Based Healthcare payment models create a reimbursement incentive for healthcare providers to think more broadly about health and to establish new partners in providing more integrated and holistic care. This shift toward increased collaboration, outcome-based payment and new benefit design is driving innovation in how healthcare is paid for and delivered. In particular, it establishes a need for healthcare systems to build mechanisms to address patient and family engagement and social determinants of health.Patient-Centered Health Advisory Council The Patient-Centered Health Advisory Council serves as a key resource for feedback and recommendations to IDPH, the legislature, and other stakeholders on issues related to implementation of health transformation initiatives in Iowa. Additionally, the Patient-Centered Health Advisory Council:encourages partnerships and synergy between community healthcare partners in Iowa who are working on new system-level models to provide better healthcare at lower costs by focusing on shifting from volume to value based healthcare. convenes stakeholders and leaders from all sectors of the healthcare system in Iowa to build relationships, and streamline efforts. educates the public and stakeholders on emerging healthcare transformation initiatives.Visit the Council’s website here: Issue Brief was developed by the Patient-Centered Health Advisory Council as an educational tool for the public and stakeholders as an emerging healthcare transformation topic.Population-Based Healthcare NURS 4010 – Family, Community, and Population-Based Care Research Paper

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Why Shift to Population-Based Healthcare? The current U.S. healthcare system was designed to manage illness and disease -not to necessarily promote health and prevent disease. It is widely acknowledged that the current system is overwhelmed by fragmentation, inefficiencies, wide variation in both quality and cost, and primary focus on the treatment of illness rather than population health improvement and management. Additionally, U.S. health expenditures are high, going up, and unsustainable. View this short video explaining in simple terms what value-based payment is and why the U.S. is shifting to this payment model.The Next Step: Population-Based Healthcare on a Community Level The movement towards value-based care could potentially have an unintended consequence and discourage providers from caring for sicker patients who may have multiple social needs. Providers could be held accountable for the health impacts caused by these social needs even though they have limited ability to control them. New innovative payment models are taking population-based care to the next level and creating the infrastructure for integration of community-level population health.NURS 4010 – Family, Community, and Population-Based Care Research Paper A provider’s target population is no longer being limited to their individual patients but now extends to their larger community and the collective health of that community. This transformation recognizes that most individuals will only be as healthy as the community in which they live. The CDC published a report called “Towards Sustainable Improvements in Population Health” that gives an overview of community integration structures and emerging innovations in financing. The report can be accessed here: the Centers for Disease Control and Prevention (CDC) continues to move towards the Triple Aim, new innovative payment models must shift the emphasis of health from the provider office level to a healthcare system that addresses other influences on health for a larger community. The Triple Aim includes improving the patient experience, improving the health of populations, and reducing the cost of healthcare.

Community health is a major field of study within the medical and clinical sciences which focuses on the maintenance, protection, and improvement of the health status of population groups and communities. It is a distinct field of study that may be taught within a separate school of [public health] or [environmental health]. The WHO defines community health as:NURS 4010 – Family, Community, and Population-Based Care Research Paper

environmental, social, and economic resources to sustain emotional and physical well being among people in ways that advance their aspirations and satisfy their needs in their unique environment.[1]

Community health tends to focus on a defined geographical community. The health characteristics of a community are often examined using geographic information system (GIS) software and public health data sets. Some projects, such as Info Share or GEO PROJ combine GIS with existing data sets, allowing the general public to examine the characteristics of any given community in participating countries.

Medical interventions that occur in communities can be classified as three categories: primary healthcare, secondary healthcare, and tertiary healthcare. Each category focuses on a different level and approach towards the community or population group. In the United States, community health is rooted within primary healthcare achievements.[2] Primary healthcare programs aim to reduce risk factors and increase health promotion and prevention. Secondary healthcare is related to “hospital care” where acute care is administered in a hospital department setting. Tertiary healthcare refers to highly specialized care usually involving disease or disability management.

The success of community health program mes relies upon the transfer of information from health professionals to the general public using one-to-one or one to many communication (mass communication). The latest shift is towards health marketing.

As family physicians, our satisfaction at the end of a day comes from knowing that our patients received quality care. Often, a few encounters will remind us that we truly make a difference in their lives: the adult with severe dyspepsia who is now stable after successful dieresis, the child with asthma who has remained symptom-free for a year, the smoker who finally succeeded in quitting after years of your urging. Our primary motivation for choosing this profession was our desire to be effective healers for all people who call us their personal physicians.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Yet how do we know we’re extracting and applying the best medical knowledge and skills from the ever-expanding universe of medical literature? As important, how do we know we’re providing quality care to every one of our patients when we examine or talk with only a small fraction of them each day? Family medicine educators might re frame these questions this way: How do we use evidence-based guidelines to practice population-based health care? Others might simply ask, “How do we provide the best care for all our patients?”

These questions may seem easy to answer. Some family physicians who have had stable patient panels for more than a decade tell me they “know” everyone with diabetes or asthma, everyone who smokes and others at risk and that they just “know” these patients are receiving the best care possible.NURS 4010 – Family, Community, and Population-Based Care Research Paper Yet many family physicians in today’s rapidly changing health care environment find they need to develop a more methodical and proactive approach to caring for their patient populations — a “systems approach” to primary care. A systems approach involves collecting data to help you identify and monitor those who need care; finding and implementing the latest care guidelines; and involving your office staff, nurses, other physicians and other caregivers in evaluating and improving your performance.

In helping us serve all our patients more effectively, a systems approach to primary care also helps us show the quality of our care to those who demand evidence. We family physicians increasingly are being asked by patients, fellow physicians, health plans and regulatory bodies to demonstrate objectively that our care really does make a difference and that our effectiveness extends to the entire population we care for, regardless of whether we’ve actually seen those patients recently.NURS 4010 – Family, Community, and Population-Based Care Research Paper

This article describes a four-step systems approach that optimizes primary care for our patients with certain conditions:

  1. Choose common conditions that lend themselves to a systems approach to care,
  2. Identify the patients in your practice with those conditions,
  3. Choose measurable outcomes that reflect the best evidence-based medical practice,
  4. Regularly measure and try to improve these outcomes.

These four steps employ the principles of continuous quality improvement — that is, the notion that we can improve our care if we carefully choose and continuously monitor the outcomes we want to achieve and continuously explore ways to improve our system of care.

The extent to which a particular practice can implement this approach depends on many factors, such as your location (rural or urban); setting (solo, small group, multi specialty group or integrated health system); available resources (such as your computer system); and the availability of support services (such as home-health nurses, case managers and nurse telephone services) from your group, your health system or a particular health plan. The group practice with a large, relatively stable panel of capita ted patients is ideal for the systems approach, although many other practices can approximate it to good effect.NURS 4010 – Family, Community, and Population-Based Care Research Paper

How the work required to implement this model is paid for will also depend on your situation. If you’re in a heavily capita ted practice and you share risk for downstream utilization, proactive population-health programs are in your economic interest because they help keep patients from needing the services for which you’re reimbursed only on a per-member-per-month (PMPM) basis. Even better, some capitation plans reimburse separately (beyond the PMPM payment) for services such as immunizations and visits by home-health nurses — services that can be important parts of the systems approach.

Even under discounted fee for service, you can recoup some of the costs of population health care by using codes that accurately reflect the services you and your staff provide. For example, you can bill for preventive medicine counseling using codes 99401-99404, immunizations using codes 90700-90749 and home visits using codes 99341-99350 (although not all insurers will cover these visits when they’re provided by nurses rather than physicians). Also, be sure your coding reflects the true complexity of your visits with these patients when they do come to the office (of course, you’ll need thorough documentation in this era of heightened scrutiny for health care fraud). NURS 4010 – Family, Community, and Population-Based Care Research Paper  Other components of population- health programs, such as enhanced computer systems or staff time involved in identifying eligible patients and reviewing their charts, may not be reimbursable.NURS 4010 – Family, Community, and Population-Based Care Research Paper

In the end, your population-health program may depend largely on the resources you can devote to it, your own initiative and your commitment to doing what’s best for your patients. Remember that you can implement this approach in stages. The keys are to be proactive, creative and realistic about what you can accomplish.

1. Choose the right condition

Choosing the right clinical condition is critical to the success of population-based care. Before applying this approach to any group of patients, ask yourself whether the condition meets the following criteria:

  • The condition is commonly encountered in primary care;
  • The cost and human burden of the condition is significant;
  • Evidence exists of wide variations in care or outcomes (or such variations are likely);
  • Evidence exists that best practices lead to predictable, improved outcomes;NURS 4010 – Family, Community, and Population-Based Care Research Paper
  • Appropriate evidence-based practice guidelines are available;
  • Family physicians can provide most of the care the condition demands;
  • Patient education and support can help improve outcomes;
  • Best practices and outcomes are measurable, reliable and relevant.

Based on these selection criteria, you can identify a special subset of acute and chronic conditions, as well as important preventive services, that lend themselves to a population-based approach. Here are some examples:

  • Acute conditions such as headache, low-back pain, otitis media, urinary tract infection and myocardial infarction;
  • Chronic diseases such as congestive heart failure (CHF), asthma, diabetes and hypertension;
  • Preventive services such as immunizations, Pap smears and mammograms;NURS 4010 – Family, Community, and Population-Based Care Research Paper
  • Preventive counseling in areas such as diet, exercise, smoking cessation and cessation of the use of alcohol and other drugs.

2. Identify patients with the condition

Once you choose a condition or a preventive service, you must develop a system to identify the patients in your practice who have the condition or need the preventive service.

First, clearly define a target population according to variables such as age, gender and specific medical data. For example, if your focus is immunizations, the target populations may be your two-year-old patients, your patients over age 65 or your pregnant patients. If your focus is a chronic disease, the target population might be all patients with the signs and symptoms of the disease or just those who have been hospitalized with that diagnosis. How you define your target population will clearly affect the size of the population and the scope of your project.

Then define the condition clinically in a way that will identify the patient population accurately and make the identification process feasible. The capabilities of your computer system may largely determine what you can accomplish. For example, if you use a computerized patient record (CPR) system, it may be as simple as pushing a few buttons to identify all patients with asthma, all patients with CHF who have a recent ejection fraction of less than 40 percent, or all adults over age 65 and all other patients with medical conditions that require annual influenza vaccinations.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Without a CPR system, you will be more limited in the patient populations you can identify accurately and feasibly. For example, if you use your computer system only for patient demographics and billing, you could identify patients over 65 but perhaps not those who should be vaccinated because of their medical conditions. This illustrates why many see CPRs as the phone and fax of the 21st century — tools family physicians won’t be able to practice without.

Even without a CPR system, you can create a system to identify most of your patients with the condition you select. For example, you could ask your patients to fill out a simple survey added to your patient intake form or have your staff review your charts and apply colored dots to indicate certain diagnoses or conditions (e.g., red dots for all current smokers, green dots for all children who need to be immunized or heart stickers for all patients with CHF). To limit the number of chart reviews, you may be able to use your billing system to identify patients with certain conditions by searching for ICD-9 or CPT codes.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Ideally, you would review your entire patient population, but your computer system, staff time and expertise may limit what’s feasible. If you can identify 50 or more patients who have a target condition and for whom your care may vary from the “best practice,” you probably have a large enough group to make population-based care worth your effort. The key point here, and the essence of continuous quality improvement, is that you need to start somewhere and can always improve.

3. Choose outcomes linked to guidelines

Once you identify a condition or preventive service and a target population, choose measurable outcomes that result from following high-quality, evidence-based care guidelines. The outcomes you choose will be the bases for evaluating the success of your program.

What outcomes are reasonable to measure depends on many variables, including the condition you target, the capabilities of your computer system and the amount of effort you can expend. For example, although you can measure your effectiveness in managing hypertension by tracking admission rates for hypertensive emergencies, stroke and myocardial infarction, this may require a complex methodology and a sophisticated information system. But other outcomes related to hypertension — such as the percentage of hypertensive patients who have normal blood pressure readings or the percentage of hypertensive patients who don’t use tobacco — are easier to measure. Your nurse could maintain a simple computer spreadsheet or a handwritten log to track such variables as name, date of visit, blood pressure reading, whether the patient smokes and date of next visit.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Whatever outcomes you select must be linked to evidence-based care guidelines, since the guidelines justify the effort. For example, the percentage of patients who have controlled hypertension and who don’t smoke is an appropriate outcome to measure because consensus guidelines exist for managing hypertension, and clinical studies demonstrate that controlling hypertension and eliminating smoking reduces morbidity and mortality from hypertensive emergencies, stroke and myocardial infarction.

Clinical guidelines for a variety of conditions have been published (see “Sources of clinical guidelines”). They can help you avoid reinventing the wheel for your own practice.

Sources of clinical guidelines

The Agency for Health Care Policy and Research (AHCPR) is perhaps the most important resource for clinical guidelines. The agency supports research to improve health care quality, reduce its cost and broaden access to essential services.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Seventeen AHCPR-supported, evidence-based guidelines are available online at (You can also contact the AHCPR publications department at 800-358-9295.) These include guidelines for managing acute pain, urinary incontinence, cataracts, depression in primary care, sickle-cell disease in infants, early HIV infection, benign prostatic hyperplasia, cancer pain, unstable angina, heart failure, otitis media in children, acute low-back problems and pressure ulcers. Other guidelines cover stroke rehabilitation, cardiac rehabilitation, prevention of pressure ulcers and mammography.

In 1996, AHCPR announced it would stop developing practice guidelines and instead support guideline development by other groups. In that role, AHCPR is collaborating with the AMA and the American Association of Health Plans to develop the Internet-based National Guideline Clearinghouse (NGC), which will offer online access to guidelines developed by a variety of public and private organizations. In April, the agency formally invited health care organizations to submit guidelines for inclusion in the NGC. The clearinghouse is expected to be up and running this fall, and its web address will be 4010 – Family, Community, and Population-Based Care Research Paper

Also available from the AHCPR web site is the Guide to Clinical Preventive Services published by the U.S. Preventive Services Task Force. The guide contains recommendations for screening services, counseling services, immunizations and chemo prophylaxis to prevent more than 80 conditions.

The AAFP is another resource for guidelines. They appear frequently in American Family Physician, and you can find the Academy’s current guidelines on the AAFP web site ( Other primary care guidelines are available from the American College of Physicians ( and the American Academy of Pediatrics (

The AMA publishes the Directory of Clinical Practice Guidelines. Updated annually, the directory lists about 1,900 guidelines published by 80 medical organizations and government agencies, but it doesn’t provide the guidelines themselves. For more information, call the AMA order department at 800-621-8335.

Keep in mind that simply because a guideline is published doesn’t guarantee that it’s evidence-based. Evaluate guidelines carefully before putting them into action.NURS 4010 – Family, Community, and Population-Based Care Research Paper

4. Measure and improve performance

The final step in implementing population- based care is to set up a system for regularly measuring and improving your outcomes. Again, being proactive is the key.

When caring for a population, you should measure outcomes for all your patients with the targeted condition, not just those who come to your office. This is largely what differentiates population-based care from traditional, individual-centered care. For example, if your target outcome is that all hypertensive patients will have blood pressure within normal limits, documented by twice-a-year readings, then you must identify those who haven’t been in the office for a recent blood pressure check and let them know they need to come in. Computer programs are available (to augment a CPR system) that can identify patients who meet given criteria, create letters and even place telephone calls to them, reminding them to have their blood pressure checked.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Even without a CPR system, you can implement simple office procedures to accomplish the same task. For example, your staff could review the spreadsheet or handwritten log of hypertensive patients to identify those who failed to keep appointments, those who simply have not been in to see you for some time and those with poorly controlled blood pressure. These patients would be targeted for telephone and office follow-up.

In addition to monitoring all your patients with a given condition, you must ensure that those patients actually receive optimal care. Once again, this may require proactive efforts to reach patients, educate them and monitor their results. For example, suppose your chosen outcome is that no children with asthma will be seen in the emergency department or admitted. Evidence-based guidelines suggest you can accomplish this if all patients know and avoid their asthma triggers, use their inhaled medications properly, learn to measure their peak flow and have a patient-initiated treatment plan for acute exacerbation’s. Meeting these guidelines may require that you send a home-health nurse to do environmental assessments, teach patients to use inhalers, review patient-initiated plans for exacerbation’s and tell patients whom to call with after-hours questions. Finally, your staff (or volunteers from among your patients or the community, if you have access to them) may need to contact all asthma patients who miss their regular appointments or periodically call parents of children who have moderate or severe persistent asthma.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Finally, to improve your performance, it’s important to evaluate your care outcomes regularly and consider improvements. For example, you might schedule quarterly review meetings with your office manager and (depending on how ambitious your effort is) physician colleagues, home-health agency staff, patient or community volunteers, and others involved in your population-health initiative. You might survey your patients with the targeted condition and your staff to identify barriers to meeting your goals and determine how to overcome them. You can’t fix what you don’t know is broken.

The systems approach in action

Does a primary-care systems approach to managing patient populations really work? Let’s use the four steps described earlier to review how you might implement it. Then we’ll examine some results of a CHF program instituted to help the primary care physicians and members of Av Med Health Plan, a Florida-based, nonprofit HMO. The program is directed by primary care physicians.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Step 1: Choosing the condition. Almost 5 million Americans have CHF, and family physicians commonly treat them. CHF is the leading cause of hospitalization for people older than 65; it contributes to 250,000 deaths annually and costs $10 billion each year. The five-year mortality rate approaches 50 percent in some studies. Research has demonstrated that adopting practice guidelines for CHF leads predictably to improved outcomes, and a set of evidence-based practice guidelines (“Heart Failure: Evaluation and Care of Patients With Left- Ventricular Systolic Dysfunction”) is available from the Agency for Health Care Policy and Research (AHCPR). Family physicians can provide most CHF care, and both physician and patient education can help improve outcomes. Measurable, reliable and relevant outcomes can be identified.

Step 2: Identifying patients. Most patients with signs and symptoms of CHF have left-ventricular systolic dysfunction revealed by an ejection fraction on electrocardiography of less than 40 percent. For this program, the target population would be all patients who meet the clinical diagnosis of CHF (e.g., dyspepsia, poor exercise tolerance, rales, etc.) and have an ejection fraction of less than 40 percent. If you use a CPR system, you could identify these patients through a series of database queries. Alternately, your nurse or office manager could maintain logs of all patients with this diagnosis by reviewing claims records, administering a survey to all patients or reviewing charts.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Step 3: Choosing outcomes linked to guidelines. From the AHCPR guidelines for CHF, you could identify and measure a number of key outcomes, such as these:

  • Patients receive a prescription for an angioplasty-converting enzyme (ACE) inhibitor and adhere to their regimens,
  • Patients record their weight daily,
  • Patients contact the physician’s office if they note weight gain of three to five pounds in a week or since the previous visit.

The patients’ weight logs also would include their weights at the beginning of the program and when you prescribe the ACE inhibitor. You would ask patients to bring their weight diaries to office visits, and staff would record their weights at those times as well.

Because non adherence is a major cause of morbidity and avoidable hospital admissions, your staff (or volunteers) might need to contact patients with more severe heart failure (e.g., those with a recent hospitalization or with dyspepsia on minimal exertion) every couple of weeks to make sure they have scales in their homes, are recording their weights daily, are taking their medications, haven’t gained weight and don’t have worsening symptoms. For patients whose adherence is in doubt, you might need to have a home-health nurse conduct a home assessment and provide additional education and support.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Other important outcomes could include reducing hospital admission rates and maintaining or improving patients’ perceptions of quality of life. But measuring these outcomes requires computers, access to survey tools (such as the SF-36 Health Survey, which measures perceived quality of life) and careful attention to methodology.

Step 4: Measuring and improving performance. Based on data from patient visits and proactive phone calls, your staff could track these variables related to your targeted outcomes:

  • The number of your patients with CHF,
  • The date of their last office visits,
  • The number and percentage of those who keep a daily weight diary,
  • The number and percentage of those who take their ACE inhibitors,
  • The number and percentage of those who gain more than three to five pounds and those who call the office if they do,
  • The number of hospitalizations for CHF among these patients.

For those who are readmitted, you would try to find out why. Were they taking their medications? Were they keeping daily weight diaries? Did they remember to call the office when they gained weight? Had they visited the office recently? Did your staff call them to check on their clinical status? Answers to these questions could suggest strategies for managing CHF more effectively.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Results of a systems approach

Our health plan implemented a program, called Healthy Hearts, following the model outlined above. After receiving approval from 225 CHF patients and their primary care physicians, Av Med’s nurse case managers and home-health nurses conducted home assessments, patient education and telephone follow-up. We found that when the patients entered the program, more than half didn’t even own scales, much less check their weight daily. So Av Med purchased scales for these patients. (Yes, this is clearly an advantage of working in a fully capita ted environment; the scales were necessary for effective care, and we were fairly sure they would pay for themselves in reduced health care costs.)NURS 4010 – Family, Community, and Population-Based Care Research Paper

Here are the clinical results of the program after only six months (comparisons are with data collected before the program began): The percentage of patients taking ACE inhibitors increased from 60 percent to more than 70 percent; readmission for CHF decreased by 40 percent; and admissions for non-VHF causes (such as pneumonia and myocardial infarction) decreased by almost 50 percent.

Based on pre- and post enrollment surveys of quality of life, the CHF population’s perceived health didn’t decline during this time; in fact, a number of patients rated their own health as improved. This is an accomplishment given the worsening natural history of untreated CHF. Up to half of the patients in some studies died within five years of diagnosis.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Of course, you don’t have to take my word for it. The literature offers several examples of the benefits of a systems approach to primary care. (See “Suggested reading.”)

Implementing a systems approach

How to implement a primary care systems approach to population-based medicine depends largely on your type of practice. Some health plans, integrated delivery systems and large group practices already are providing population-based care by forming quality improvement committees to identify conditions, establish outcomes, review and approve care guidelines, and involve their nurses and other health professionals to assist physicians in outreach and education.

With determination and creativity, a solo family physician or small group can make this approach work, too. The major differences may be the number of conditions you can afford to target and the scope of the interventions you can afford to implement. Here are some concrete suggestions:NURS 4010 – Family, Community, and Population-Based Care Research Paper

  • Use the clinical guidelines and other materials available from national organizations such as AHCPR to help you develop population-health programs.
  • Seek out local resources to be part of your practice’s primary care system. Contact the local hospital, home-health agencies, pharmacies and pharmaceutical companies, the public health department and health-related associations such as your local American Heart Association chapter. You might ask them for help in setting up computerized tracking systems, developing surveys, conducting home visits or providing patient education materials and support.
  • Consider soliciting volunteers from local organizations to make follow-up calls and the like.NURS 4010 – Family, Community, and Population-Based Care Research Paper
  • Contact your health plans for assistance. All health plans accredited by the National Committee for Quality Assurance provide ongoing quality improvement programs targeted at common conditions and preventive services. So your plans may already have resources to help you reduce hospital admissions for asthma patients or improve immunization rates. Many plans will help you care for their members by arranging or performing home assessments and education, providing after-hours telephone advice and triage services staffed by nurses, providing clinical pharmaceutical and specialty consultation services, sending patients educational materials and helping you monitor the progress of your population-based care.

Ideally, health plans should work together on these initiatives, but in practice they target only their own members. If you have contracts with multiple health plans, you’ll get the biggest bang for your buck by working with those that cover the largest percentage of your patients. The plans’ medical directors usually are your best points of contact. And if you’d like to gain skills and experience in quality improvement and population-based health care, you can ask to serve on these plans’ local quality improvement committees.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Community and Population Health

Community Health: Overview

Community health is generally rooted in the collective efforts of individuals and organizations who work to promote health within a geographically or culturally defined group.3,4 Community health initiatives function as “multi-sector and multi-disciplinary collaborative enterprises”3 that use evidence-based strategies to “engage and work with communities, in a culturally appropriate manner.”3 The progress and success of these initiatives originate from the community members, who are collectively empowered to address self-identified vulnerabilities (eg, education, employment, public safety). In other words, the community and its relevant characteristics are—in and of themselves—considered to be “an essential determinant of health”4 for each individual who is part of, or becomes affiliated with, a community’s given membership.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Population Health: Overview

Population health, alternatively, uses an outcome-driven approach to “manage” health for a specific group of individuals, typically defined by attribution.5-7 These interventions involve the tracking and measurement of “health status indicators”7 (eg, high blood pressure, cholesterol) within these groups to provide insight and direction on how to best prevent the onset or future development of certain health conditions (eg, ischemic cardiac disease). Health determinants, such as healthcare access, genetics, and individual behavior, also tend to be included in this description, as they play an influential role in an individual’s history and current health status.7 Given their nature, the majority of population health interventions tend to be led by healthcare organizations, including ACOs, who have a responsibility—financial or otherwise—to report outcomes involving the patients under their management or care.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Population Management

Population health management aims to improve the health of everyone in a clinical practice. For diabetes care providers, the goal is to satisfy the needs of every patient with diabetes under their care, even if the person has not made an appointment or been seen in the office for extended periods of time. Closely linked to the concept of a patient centered medical home, population health management techniques focus on providing proactive support to a defined and prepared patient population. Driven by increasing use of population-based process and performance improvement measures, population health management relies on the ability to provide patient support between clinical visits and to enhance clinical decision support for more comprehensive care delivery during a clinical visit. The ability of these techniques to improve both quality of care delivery and patient safety helps to explain why diabetes is the most commonly adopted focus of new patient centered medical homes.NURS 4010 – Family, Community, and Population-Based Care Research Paper

“Successful practices know who their patients with diabetes are, and regularly mine the data to ensure they receive the care they need.1

The ability to identify and track patients during the care process is an important advancement provided by creation of a diabetes registry. There are two basic types of electronic registries: registries that are built into an electronic health record (EHR) and those that stand alone outside of an EHR. Most systems are moving to HER-integrated registries given their existing and potential advantages over stand-alone registries.

Visit the Information Systems section for more information about registries and EHRs.

What a Registry Can Do for Your Practice

A patient registry enables a practice to track its diabetes population and proactively organize and plan care. Successful registries drive change in practice and work flows. In addition, successful registries function at several levels, providing support for population management, individual care management, and point-of-care management.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Population Management

Process and performance reporting allows health care practices and providers to measure compliance across their patient population around a specific measure. For example, a common diabetes measure is the number of patients in the defined population with an A1C less than 7%. The definition of the specific population that forms the “denominator” can vary widely. For a payer organization or a closed health care system, the population may be defined as all patients with continuous health care coverage provided by the payer. For independent practices, all patients who have visited the practice twice over the last 24 months are generally included. Population-based reports provide information on quality and patient safety. They may also provide insight into practice patterns and a comparison between peer groups.

Care Management

The registry can generate lists of patients that can be used to remind patients and health care team members about services that are needed. By reminding patients of recommended lab tests and visits, registries support active care coordination between visits and encourage patients to return for necessary care. Patient-specific physician reminders can then be used during per-visit planning to ensure that when a patient does return to the practice, opportunities to receive recommended care are not missed. If lists of patients are not easily generated from the EHR, ask your lab or billing provider whether they can generate specific lists. For example, your lab may be able to quickly generate a list of all of your patients with an A1C between 8% and 10% and between a certain age group.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Point of Care

The ability to support clinical decision making at the point of care can be very effective in improving care. This includes interventions that are provided at the time of the patient visit, such as the development of patient-specific alerts that notify the provider during the patient visit of specific recommended care processes. For example, an alert can notify the provider during a visit that a patient is overdue for an A1C or a foot exam. Point-of-care interventions are technically challenging since they must be integrated into existing work flows and may require modification or interaction with the existing EHR.

Effective registries change the existing work flow in a practice. They require accurate and granular data, and they need to organize data so that patterns in care delivery are apparent. A good registry should provide staff with actionable information and perform reliably. Barriers include cost, the disruption of process and workflow changes, and challenges of interoperability between systems. Current limitations of existing systems are common, and reimbursement for the work of coordination is often limited. However reimbursements are clearly moving away from fee-for-service to value-based models.NURS 4010 – Family, Community, and Population-Based Care Research Paper

Community & Population Health

Community support of the local health care system is vital for sustainability and growth. Navigating the transition from volume to value-based payment and population health within hospitals as well as with the community begins with setting a course based on a strong assessment and good planning. Learn how to create a healthier and more engaged community by working with The National Rural Health Resource center (The Center). The Center’s services may be selected as a single Community Health Needs Assessment service or a package of services, depending upon organizational or community need. In all cases, The Center’s assessment tools provide tangible outcomes designed to match an organization’s vision, mission and strategic goals.

Healthy Hospital, Healthy Community Bundle

The Center recommends the following services as you transition toward population health.NURS 4010 – Family, Community, and Population-Based Care Research Paper

  • Six-page Community Health Needs Assessment
  • Focus Group Sessions
  • Secondary Data Collection
  • Implementation Planning

Starting at $16,000 plus travel

Community Health Needs Assessment

The Center has assisted hundreds of hospitals and health councils during the past 25 years with community health needs assessments (CHNA) and marketing surveys. The assessments include:

  • Survey development
  • Random sampling and mailing list creation
  • Survey printing and distribution, tabulation and summary of results, including comparison with The Center’s rural database
  • Presentation of survey findings and recommendations to local governing board

Pediatricians traditionally focus on the care given to patients as they come into the office, one after the other.  There is little choice but to be there and wait for them. Before the advent of modern technology, there were not tools to manage patients as a group – for instance, those who need specific preventive measures or those afflicted by a common disease or condition (asthma, obesity).NURS 4010 – Family, Community, and Population-Based Care Research Paper

Up to now, a predominantly fee-for-service (FFS) payment system has encouraged episodic face-to-face encounter activities with individual patients. In this environment, it has even been difficult to be paid for episodic group encounters to educate patients with the same condition. It’s true that some, to their enormous credit, have taken the time and effort to advocate and care for children in different venues, but this work has been done pro bono, on one’s own time and one’s own dime.

Times, however, are changing. New technologies such as digitized billing records and electronic medical records and new communications media now give capabilities to know about and to reach patients and communities as never before. The scientific knowledge base is increasing as well, due to investigative work on prevention and the social determinants of health (especially poverty), and the development of new interventions. Even payers are starting to change, as they develop Alternative Payment Methodologies. Practices may finally be paid for services beyond individual, face-to-face encounters. It is also possible that as pediatric practices coalesce into larger groups, their greater financial and organizational strength might facilitate harnessing the new technologies, although it is certainly true that agile smaller practices can also devise innovative ways to manage groups of patients.  NURS 4010 – Family, Community, and Population-Based Care Research Paper

In sum, although it is too early to tell, it is possible that pediatrics may be entering an era where Population Health (PH) interventions are feasible. Public health and health policy experts have long looked at populations and tried to discern what interventions would create the best outcomes for the greatest number, while clinicians have cared for patients on a one-by-one basis. New technologies can enable clinicians to apply public health perspectives to practice. Perhaps the new PH mindset is best thought of as a change from passivity to pro activity of the clinician group. While the individual relationship of patient to doctor must never, ever be lost, and still comprises the essence of pediatric practice, the ability to reach out actively to groups is novel and offers powerful and exciting new possibilities.​ NURS 4010 – Family, Community, and Population-Based Care Research Paper

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