An Introduction to Population Health from Clinical and Public Health Perspectives: Population Health Basics.

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1 An Introduction to Population Health from Clinical and Public Health Perspectives: Population Health Basics

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7 Continuing Education Credit Public Health Health Education Certificate of Attendance

9 Module 1 Population Health Basics

10 Barbara L. Massoudi, PhD, MPH Senior Advisor, RTI International, ehealth, Quality and Analytics Division Adjunct Associate Professor Rollins School of Public Health, Emory University

11 Where do you work? Image Source: istock

12 How do you anticipate this new information and knowledge will impact your work? Image Source: istock

13 An Introduction to Population Health from Clinical and Public Health Perspectives This series is comprised of 4 modules. Module 1 Population Health Basics Module 2 Data for Population Health Module 3 Population Health Analyses Module 4 Developing a Population Health Plan

14 Objectives for Module 1 Population Health Basics Contrast the definition of population health with that of public health, community health, and the management of patient panels Describe several examples of the application of population health analysis in community health and primary care Utilize a conceptual model to describe how population health relates to adjacent fields List three questions that population health analyses can answer

15 What is Population Health? Term population health first used in 1990 s Promoted by CMS and the Institute for Healthcare Improvement Triple Aim The health outcomes of a group of individuals, including the distribution of such outcomes within the group. Mandated by the Affordable Care Act and HITECH What does this definition actually mean? Simultaneously improving the health of the population, enhancing the experience and outcomes of the patient, and reducing per capita cost of care for the benefit of communities. X Image Source: istock

16 Three Views of Population Health

Does Public Health = Population Health? Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy.

17 Does Public Health = Population Health? Public health is what we, as a society, do collectively to assure the conditions in which people can be healthy. Public health is literally the health of the public as measured in terms of health and illness. Population Health = The health outcomes of a group of individuals, including the distribution of such outcomes within the group. Image Source: istock

18 Does Community Health = Population Health? The health characteristics of populations within a shared geographical area. The health status of a defined group of people, or community, and the actions and conditions that protect and improve the health of the community. Population Health = The health outcomes of a group of individuals, including the distribution of such outcomes within the group. Image Source: istock

19 Does Management of a Patient Panel = Population Health? A set of tools and processes for population care that are applied systematically at the level of a primary care panel, with PCPs directing proactive care for their empaneled patients. Processes that close identified care gaps to ensure all patients in our panel get recommended preventive screenings and chronic disease care. Population Health = The health outcomes of a group of individuals, including the distribution of such outcomes within the group. Image Source: istock

Population Health in the Literature I Combining clinical and population-level data to understand the health of neighborhoods. (Chambers et al.

20 Population Health in the Literature I Combining clinical and population-level data to understand the health of neighborhoods. (Chambers et al., 2015) Examined health behavior question responses in primary care clinics in the Bronx Used electronic health record data to compare responses of patients of the clinics to the general neighborhood population Clinic patients showed a higher proportion of unhealthy behaviors Further analyses of the clinical data will look at targeting high risk populations

21 Time to Choose Image Source: istock

22 Population Health in the Literature II The interface between primary health care and population health: challenges and opportunities for prevention. (Harris, 2016) Focus on preventive services as part of primary care Use the 5 A s: ask, assess, advise/agree, assist and arrange Provide linkages to other providers, programs, and services Practical nurses function as preventive health navigators

23 Time to Choose Image Source: istock

24 Population Health in the Literature III Observations illustrating the use of health informatics to link public health immunization registries and pharmacies to increase adult immunization rates and improve population health outcomes. (Popovic, 2016) Case studies of early pharmacy adopters of immunization registries in Washington state Effort to improve capture of immunizations being provided in non-traditional care settings and provide additional opportunities for immunization Results showed opportunities for immunization and increased benefit for linking pharmacies with immunization registries Administration of immunizations was highly correlated with particular pharmacists.

25 Time to Choose

26 Population Health in the Literature IV Using Electronic Health Records for Population Health Research: A Review of Methods and Applications. (Casey et al., 2016) Use of EHRs to conduct epidemiologic investigations for population health research Compared EHR epidemiology to traditional epidemiologic methods EHR studies were found to be less expensive, and took less time Traditional epi methods produced more reliable data and better patient retention Recommendations for improving EHR data are included

27 Time to Choose Image Source: istock

28 Population Health Conceptual Model Slide Clinical Healthcare Healthcare System Total Population Provider Organization Clinician Target Population Patient or Consumer Population Health Public Health Image Source: Kharrazi, 2016

29 Population Health Framework Population Risk Factors/Determinants Behaviors Genetics Physical Environment Social Environment Healthcare Outcomes Illness Injury Deaths Quality of Life Disparities Gender Geography Race/Ethnicity SES Policies and Programs Source: Adapted from Kindig et al., 2008

Conclusion and Wrap-Up Next presentation: What questions can you answer with population health analyses? What data sources are available to use for these analyses?

30 Conclusion and Wrap-Up Next presentation: What questions can you answer with population health analyses? What data sources are available to use for these analyses? Send the relevant questions for your organization by end of day tomorrow: Feel free to send any other questions you have Image Source: istock

31 References Casey, J. A., et al. (2016). "Using Electronic Health Records for Population Health Research: A Review of Methods and Applications." Annu Rev Public Health 37: Chambers, E. C., et al. (2015). "Combining clinical and population-level data to understand the health of neighborhoods." Am J Public Health 105(3): Harris, M. (2016). "The interface between primary health care and population health: challenges and opportunities for prevention." Public Health Res Pract 26(1): e Kharrazi, H., et al. (2016). "A proposed national research and development agenda for population health informatics: summary recommendations from a National Expert Workshop." J Am Med Inform Assoc. Popovich, M., et al. (2016). "Observations Illustrating the Use of Health Informatics to Link Public Health Immunization Registries and Pharmacies to Increase Adult Immunization Rates and Improve Population Health Outcomes." Online J Public Health Inform 8(2): e185. Kindig DA, Asada Y, Booske B. (2008). A population health framework for setting national and state health goals. JAMA. 299(17): doi: /jama

32 Questions? Image Source: istock

33 An Introduction to Population Health from Clinical and Public Health Perspectives This course is comprised of 4 modules. You have just completed module 1, Population Health Basics. Module 1 Population Health Basics Module 2 Data for Population Health Module 3 Population Health Analyses Module 4 Developing a Population Health Plan

34 Barbara L. Massoudi, PhD, MPH Senior Advisor, RTI International, ehealth, Quality and Analytics Division Adjunct Associate Professor Rollins School of Public Health, Emory University

36 Thanks for joining us! This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB6HP27882 "Regional Public Health Training Center Program" for $3,420,000. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

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