Population Health Initiatives Research Articles

Population health model for pharmacist assessment and independent prescribing of statins in an ambulatory care setting

ObjectiveThis study aimed to evaluate the impact of a pharmacist population health initiative on the ability to increase the percentage of patients with atherosclerotic cardiovascular disease (ASCVD) who are on an appropriate statin. SettingTen primary care clinics in Southwest Washington. The average payer mix across the included clinics is 47% Medicare, 26% commercial, 22% Medicaid, 2% self-pay, and 3% other. Reimbursement-tied statin quality metrics are present in 14.1% of patients’ insurance contracts. Practice descriptionThe primary care pharmacy collaborative drug therapy agreement allows pharmacists to act as prescribers by permitting initiation, adjustment, and monitoring of medication therapy, with the authority historically stemming from referral by the patient’s primary care provider to the pharmacist. Practice innovationA novel, population health protocolized prescriptive authority (PPA) initiative was implemented, of which a key component was expanding pharmacists’ prescriptive authority to prescribe statins for population health initiatives. Without referral, pharmacists screened, directly outreached to, and prescribed statins for patients with ASCVD who were not on a moderate- or high-intensity statin. Electronic health record (EHR) documentation was updated to better reflect the patient’s history and increase metric accuracy. EvaluationA retrospective analysis of a population health initiative from October 1 to December 31, 2018. The initiative was evaluated on the combined success of initiating patients with ASCVD on moderate- or high-intensity statins and the acceptance rate of EHR corrections. ResultsThe pharmacy team screened 510 patients. Appropriately dosed statins were initiated for 40.0% of patients, and the EHR was accurately updated in 91.9% of instances. These combined efforts demonstrate 50.5% overall success of pharmacist interventions. ConclusionExpanding pharmacists’ authority to PPA for statin medications in patients not meeting quality metrics increased the number of successful interventions. Pharmacists make a major contribution on improving population health metrics for statins.

Hospital Partnerships in Population Health Initiatives.

Hospitals are expected to fulfill a role in the communities they serve by improving the health of the population in the community as mandated in the Affordable Care Act. One way hospitals achieve this is to create partnerships with diverse organizations, such as local public health departments, state/federal agencies, and other health care organizations. The aim of this study is to examine characteristics of hospitals that developed partnerships based on improving population health. This study utilized the 2015 Population Health Survey, American Hospital Association Database, and Dartmouth Atlas of Health Care. Hospital characteristics included size, ownership status, part of a system, teaching status location, Medicare percentage, Medicaid percentage, average stay length, and inpatient days per 1000 persons. Level of partnership was measured by the hospital's current working relationship with other hospitals/health care systems or local/state/other agencies. Univariate, bivariate, and multivariate regression analyses were used to analyze the relationship between hospital partnerships and organizational characteristics. Hospitals with strong relationships tend to be larger and not-for-profit hospitals, hospitals with system members and located in urban areas, and teaching-affiliated hospitals. This study also found hospital characteristics were related to hospitals' partnerships. Hospitals within health care systems and with high inpatient volume were more likely to report relationships that were stronger. This study provides a systematic and updated look at hospitals' partnership when looking at commitment to population health improvement and contributes to the literature by informing about the greater need to support rural and smaller hospitals with population health outreach activities.

Developing a coordinated Canadian post-secondary surveillance system: a Delphi survey to identify measurement priorities for the Canadian Campus Wellbeing Survey (CCWS)

BackgroundInterventions that promote health and wellbeing among young adults are needed. Such interventions, however, require measurement tools that support intervention planning, monitoring and evaluation. The primary purpose of this study is to describe the process in developing a framework for a Canadian post-secondary health surveillance tool known as the Canadian Campus Wellbeing Survey (CCWS).MethodsNineteen health service providers or mental health experts from 5 Canadian provinces participated in a 3-round Delphi survey by email and an in-person roundtable meeting to identify wellbeing and health behavior measurement priorities and indicators for the CCWS.ResultsThe final CCWS framework consisted of 9 core sections: mental health assets, student experience, mental health deficits, health service utilization/help seeking, physical health/health behaviors, academic achievement, substance use, nutrition, and sexual health behavior. Panelists generally agreed on a set of indicators, and reached consensus for at least one indicator per core section.ConclusionThis CCWS framework is the first step in developing a common surveillance mechanism tailored to the Canadian postsecondary context. Future work will include online consultation with health service providers from a broader range of post-secondary institutions, an in-person meeting with research and measurement experts to finalize survey items, and formative testing. The CCWS will play a valuable role in developing population health initiatives targeting the increasing number of young Canadians attending postsecondary institutions.

Healthcare Providers Are Missing Opportunities to Capture Data that Support Population Health Programs

Data aggregation is important at every stage of population health management. A surprisingly simple (and often overlooked) way healthcare teams can collect data and gain the insights they need to successfully execute population health plans is to leverage healthcare surveys like health risk assessment surveys, medication adherence surveys, remote health monitoring surveys and gaps in care surveys. A West study found many providers and healthcare organizations can do a better job using surveys to prop up their population health initiatives. In particular, teams can take advantage of opportunities to use surveys to help prevent and manage chronic conditions across high-risk, rising-risk and low-risk subpopulations of patients.

Toolkit for Population Health Initiatives Around the Globe Related to Collaborative Comprehensive Medication Management for Children and Youth.

Almost 30 million babies worldwide are born prematurely or become ill annually and need specialized care to survive. Formalized collaborative practice agreements (CPA) between clinical pharmacists and physicians have been put forward as a means for improving the overall medicating experience in many patient populations, including children. This report briefly describes opportunities for collaboration using examples from countries on each continent where CPA is established in professional governance documents and standards. It also provides resources in the form of a toolkit for countries and pharmacist–physician collaborators to authorize and form CPAs to provide comprehensive medication management (CMM) for children and youth with special health care needs (CSHCN).

A Realist Evaluation of Local Networks Designed to Achieve More Integrated Care.

Introduction:Not surprisingly given their multi-component nature, initiatives to improve integrated care often evolve to find the best way to bring about change. This paper provides an example of how an evaluation evolved alongside such an initiative designed to better integrate care across primary, community and hospital services in South Auckland, New Zealand.Theory and methods:Using the explanatory power of a realist evaluative approach, theories of new ways of working that might be prompted by the initiative were explored in: (i) interviews with stakeholders in 2012 and 2015, (ii) online surveys of general practices and local care organisations, and (iii) a purposive sample of ten general practices.Results:The results highlighted the institutional contexts that led to difficulties in implementing population health initiatives. They also revealed that changes in work practices focussed mostly on activities that improved the coordination of care for individuals at risk of hospital admissions.Discussion:Multi-component complex interventions can vary in their delivery and be vulnerable to one or more components not being implemented as originally intended. In the case of this intervention, the move towards strengthening local relationships arose when contractual arrangements stalled. Realist evaluative approaches offer a logic that helps unpick the complexity of the relationships and politics in play, and uncover the assumptions made by those developing, implementing and assessing health service changes.Conclusion:Given the multi-component and evolving nature of initiatives seeking to better integrate care, the realist evaluative emphasis on surfacing early the theories to explain how change is expected to occur helps overcome the challenge of evaluating “a moving target”.

Should Hospital Emergency Departments Be Used as Revenue Streams Despite Needs to Curb Overutilization?

This case asks how a hospital should balance patients' health needs with its financial bottom line regarding emergency department utilization. Should hospitals engage in proactive population health initiatives if they result in decreased revenue from their emergency departments? Which values should guide their thinking about this question? Drawing upon emerging legal and moral consensus about hospitals' obligations to their surrounding communities, this commentary argues that treating emergency departments purely as revenue streams violates both legal and moral standards.

An Academic Medical Center-Based Incubator to Promote Clinical Innovation and Financial Value

Within a health care landscape characterized by increasing financial pressures, fluctuating payment models, and an increasing prevalence of clinician burnout, structures to strategically support innovation are imperative to financial and clinical success. We developed the Brigham Care Redesign Incubator and Startup Program (BCRISP), a flexible model to test, evaluate, and scale innovative care redesign proposals. We evaluated its impact via analysis of programmatic and financial data, as well as through exploration of individual project outcomes. In 5 years, BCRISP has evaluated 283 innovations, piloted 25 projects, and generated $1.8 million in total medical expense reduction and $7.1 million in increased net revenue for our institution. Initially, it was conceived as a mechanism to engage staff in population health initiatives. As shifts toward risk-based reimbursement have slowed, we have observed a similar transition among proposed and supported innovation in the program. BCRISP enabled front-line clinical employees to design and pilot solutions to common and important clinical care problems, delivering financial return and improvements in care delivery. The underlying structure has been able to adapt to the changing political and economic climate, demonstrating a flexible and powerful approach to strategic investment that could be applied broadly by many health care provider organizations.

Association of Home Respiratory Equipment and Supply Use with Health Care Resource Utilization in Children

To compare health care use and spending in children using vs not using respiratory medical equipment and supplies (RMES). Cohort study of 20 352 children age 1-18 years continuously enrolled in Medicaid in 2013 from 12 states in the Truven Medicaid MarketScan Database; 7060 children using RMES were propensity score matched with 13 292 without RMES. Home RMES use was identified with Healthcare Common Procedure Coding System and International Classification of Diseases codes. RMES use was regressed on annual per-member-per-year Medicaid payments, adjusting for demographic and clinical characteristics, including underlying respiratory and other complex chronic conditions. Of children requiring RMES, 47% used oxygen, 28% suction, 22% noninvasive positive-pressure ventilation, 17% tracheostomy, 8% ventilator, 5% mechanical in-exsufflator, and 4% high-frequency chest wall oscillator. Most children (93%) using RMES had a chronic condition; 26% had ≥6. The median per-member-per-year payments in matched children with vs without RMES were $24 359 vs $13 949 (P < .001). In adjusted analyses, payment increased significantly (P < .001 for all) with mechanical in-exsufflator (+$2657), tracheostomy (+$6447), suction (+$7341), chest wall oscillator (+$8925), and ventilator (+$20 530). Those increased payments were greater than the increase associated with a coded respiratory chronic condition (+$2709). Hospital and home health care were responsible for the greatest differences in payment (+$3799 and +$3320, respectively) between children with and without RMES. The use of RMES is associated with high health care spending, especially with hospital and home health care. Population health initiatives in children may benefit from consideration of RMES in comprehensive risk assessment for health care spending.

Urban Hospitals as Anchor Institutions: Frameworks for Medical Sociology

Recent policy developments are forcing many hospitals to supplement their traditional focus on the provision of direct patient care by using mechanisms to address the social determinants of health in local communities. Sociologists have studied hospital organizations for decades, to great effect, highlighting key processes of professional socialization and external influences that shape hospital-based care. New methods are needed, however, to capture more recent changes in hospital population health initiatives in their surrounding neighborhoods. The authors describe three promising sociological frameworks for studying the changing hospital: (1) the study of professions, (2) social network analysis, and (3) community-based participatory research. The authors argue that future analyses of hospitals and health outcomes must move beyond the internal-external dichotomy to see hospitals as complex institutions that are increasingly entwined with communities and subject to changes in state regulation.

Keeping It Contemporary: Ensuring Dynamism in an Online Population Health Course.

Population health is a dynamic area that nurses must grasp to meet the demands of the evolving health care system. Staying current on public health priorities, health policies, and population health analytic approaches poses a challenge for nurse educators. This article describes strategies used by nurse educators in a prelicen-sure population health course for student engagement on contemporary population health issues and highlights opportunities to develop skills and build competencies to lead population health initiatives. Innovations in course content, assignments, and evaluation strategies are useful in training nurses to thrive in health care systems addressing population health. Strategies to remain current on developments in the field promote population health competencies. Prelicensure nursing students can attain knowledge and skills in population health to prepare them to lead population health initiatives, analyze population-level data, provide care coordination, support complex patient groups, and optimize the use of research to promote evidence-based care. [J Nurs Educ. 2019;58(1):53-56.].

Improving the Delivery of Healthcare through Clinical Diagnostic Insights: A Valuation of Laboratory Medicine through "Clinical Lab 2.0".

As healthcare payment and reimbursement begin to shift from a fee-for-service to a value-based model, ancillary providers including laboratories must incorporate this into their business strategy. Laboratory medicine, while continuing to support a transactional business model, should expand efforts to include translational data analytics, proving its clinical and economic valuation. Current literature in this area is limited. This article is a summary of how laboratory medicine can support value-based healthcare. Population health management is emerging as a method to support value-based healthcare by aggregating patient information, providing data analysis, and contributing to clinical decision support. Key issues to consider with a laboratory-developed population health management model are discussed, including changing reimbursement models, the use of multidisciplinary committees, the role of specialists in data analytics and programming, and barriers to implementation. Examples of data considerations and value are given. Laboratory medicine is able to provide meaningful clinical diagnostic insights for population health initiatives that result in improved short- and long-term patient outcomes and drive cost-effective care. Opportunities include data analysis with longitudinal laboratory data, identification of patient-specific targeted interventions, and development of clinical decision support tools. Laboratories will need to leverage the skills and knowledge of their multidisciplinary staff, along with their extensive patient data sets, through innovative analytics to meet these objectives.

Colorectal cancer screening interventions in 2 health care systems serving disadvantaged populations: Screening uptake and cost‐effectiveness

The objectives of the current study were to assess changes in colorectal cancer (CRC) screening uptake and the cost-effectiveness of implementing multiple evidence-based interventions (EBIs). EBIs were implemented at 2 federally qualified health centers that participated in the Colorado Department of Public Health and Environment's Clinic Quality Improvement for Population Health initiative. Interventions included patient and provider reminder systems (health system 1), provider assessment and feedback (health systems 1 and 2), and numerous support activities (health systems 1 and 2). The authors evaluated health system 1 from July 2013 to June 2015 and health system 2 from July 2014 to June 2017. Evaluation measures included annual CRC screening uptake, EBIs implemented, funds received and expended by each health system to implement EBIs, and intervention costs to the Colorado Department of Public Health and Environment and health systems. CRC screening uptake increased by 18 percentage points in health system 1 and 10 percentage points in health system 2. The improvements in CRC screening uptake, not including the cost of the screening tests, were obtained at an added cost ranging from $24 to $29 per person screened. In both health systems, the multicomponent interventions implemented likely resulted in improvements in CRC screening. The results suggest that significant increases in CRC screening uptake can be achieved in federally qualified health centers when appropriate technical support and health system commitment are present. The cost estimates of the multicomponent interventions suggest that these interventions and support activities can be implemented in a cost-effective manner.

Effects of a Community Population Health Initiative on Blood Pressure Control in Latinos.

BackgroundHypertension remains one of the most important, modifiable cardiovascular risk factors. Yet, the largest minority ethnic group (Hispanics/Latinos) often have different health outcomes and behavior, making hypertension management more difficult. We explored the effects of an American Heart Association–sponsored population health intervention aimed at modifying behavior of Latinos living in Texas.Methods and ResultsWe enrolled 8071 patients, and 5714 (65.7%) completed the 90‐day program (58.5 years ±11.7; 59% female) from July 2016 to June 2018. Navigators identified patients with risk factors; initial and final blood pressure (BP) readings were performed in the physician's office; and interim home measurements were recorded telephonically. The intervention incorporated home BP monitoring, fitness and nutritional counseling, and regular follow‐up. Primary outcomes were change in systolic BP and health‐related quality of life. Using a univariate paired‐samples pre–post design, we found an average 5.5% (7.6‐mm Hg) improvement in systolic BP (139.1 versus 131.5, t=10.32, P<0.001). Quality of life measured by the European quality of life 5‐dimension visual analog scale improved from 0.79 to 0.82 (t=31.03, P<0.001). After multivariate regression analyses, improvements in quality of life and overall body mass index were significantly associated with reductions in systolic BP.ConclusionsA noninvasive, population health initiative that encourages routine engagement in patients’ own BP control was associated with improvements in systolic BP and quality of life for this largely Latino community.

Qualitative exploration of enablers and barriers to interagency collaboration from the perspectives of senior managers and executive staff including social network analysis

Introduction: The Sydney Local Health District SLHD integrated care initiative, Healthy Homes and Neighborhoods HHAN, is a comprehensive population based integrated care strategy to address the complex needs of vulnerable families. The spectrum of care required to optimise the health and social care outcomes for these families well exceeds the capacity of the public healthcare system alone. Needs such as housing, finance, and social supports often preclude these families from addressing physical and mental health issues. As part of the evaluation of HHAN, this project looks to understand the experiences of senior managers and executive staff with interagency collaboration from across the network. Theory/Methods: Recruitment took place by purposive sampling. Agencies which HHAN considers partners or potential partners were identified and an appropriate informant from within each agency selected. An agency for the purpose of this project could be within a broader organisation. The interviews focused on the participant’s individual definition of “interagency collaboration” and explored their opinions of enablers and barriers to interagency collaboration. Ideas were carried forward and explored further in subsequent interviews. To accompany the interview data, a sociogram of collaborative links was developed from an online social network analysis to provide a visual illustration of the linkages between the organisations. Results: Interviews and social network analysis data collection occurred between October 2017 and February 2018. A total of 13 semi-structured qualitative interviews took place, providing representation from six organisations. The majority of participants expressed a continuum on which they viewed interagency collaborations to be able to occur, depending on what was trying to be achieved. Achieving efficient, knowledgeable referrals with single client focus between agencies, whether government or non-government, was the most basic and common type of collaboration being aspired to. Collaboration could also include working together on shared projects and strategic planning to advance population health initiatives. The sociograms show a coherent network of collaboration with a spread of key players. Reviewing enablers and barriers, it became apparent that whether something was being characterised as an enabler or as a barrier was dependent on how the idea was being framed. As a result a thematic grouping system identifying important features of interagency collaboration is being derived, final results of which are not available at the time of this submission. Discussions: By identifying themes of identified importance to interagency collaboration from across the network, HHAN may be able to use this to optimise its ability to effectively collaborate from both a strategic and front line staff aspect. Limitations: While features of a grounded theory approach were used, strict adherence to the methodology did not take place nor did complete saturation of themes. Suggestions for Future Research: As part of the evaluation of HHAN, another project interviewing frontline staff has occurred. It may be beneficial to compare and contrast the findings from these studies, to further understand how the views of senior managers from across the network aligns with the organisational approach to interagency collaboration perceived at the client care level.

Examining the relationship between hospital ownership and population health efforts

PurposeThe purpose of this paper is to investigate the relationship between ownership type and population health initiatives adopted by hospitals using the 2015 American Hospital Association data.Design/methodology/approachHospitals of various sizes, ownership structures and geographic locations are represented in the survey. The outcome variables of interest include measures of hospital population health activities.FindingsFindings indicate that nonprofit hospitals are most likely to express commitment to population health and participate in population health activities, with for-profit hospitals being least likely. Implications for policy and practice are discussed.Research limitations/implicationsThis study demonstrates that discrepancies in population health approaches exist across ownership status – particularly, nonprofit hospitals appear to be the most likely to be involved in population health efforts.Practical implicationsAs we continue to push for population health management in the hospital setting, grappling with the definition and purpose of population health management will be essential.Social implicationsOverall, these results suggest that nonprofit hospitals are more likely to be implementing population health efforts than for-profit or government-owned hospitals.Originality/valueAlthough there are several studies on population health in hospitals, this study is the first to investigate the relationship between ownership type and population health initiatives adopted by hospitals.

Population Health Initiatives Increase Patient Engagement and Satisfaction with Health Care Services

Hardaway, John C. MD, PhD; AllardPicou, Ayana MD; Espat, Joseph N. MD, FACS; Calvino, Abdul Saied MD Author Information

Gana Burrai: applying population data linkage to more accurately measure Aboriginal maternal and infant outcomes in the Goulburn Murray Region

IntroductionThe Australian 2016 census reported Aboriginal population of Goulburn Murray Region (GMR) as being 3% of the total GMR population is considered a significant under ascertainment. This is supported by the Freemantle et al population data linkage project that reported an underestimation of 51% of Aboriginal births in Hume region.&#x0D; Objectives and ApproachThe main objective of the Gana Burrai project was to undertake a Proof of Concept (POC) project to address the critical issue the under-ascertainment of data describing Aboriginal maternal and child health outcomes within the GMR. The PoC explored the feasibility of linking a number of population administrative datasets that included information describing Aboriginal babies born and mothers and fathers living in, the GMR. The PoC also enabled an evaluation of the cultural, organisational, practical and technical issues critical to the development of this comprehensive population data set. The linkage was undertaken using GRHANITETM privacy protecting software.&#x0D; ResultsPopulation data from seven administrative datasets describing birth years 2005-2015, representing 111862 records were successfully extracted. These data represented 37,338 patients. Following the linkage process, 28,016 patient records were successfully linked. The ever-Aboriginal concept was applied to the linked data. After linkage, there was a significant under ascertainment of Aboriginal births in records maintained by the Shire of Campaspe (16%), less so by Shire of Greater Shepparton (50%); Goulburn Valley Heath (92%), and Echuca Regional Health (86%) demonstrated a more complete ascertainment. However, the linkage showed a strong correlation of patient Indigenous identity collected by the shires’/hospitals’ and the mothers’/fathers’ chance of having a record at the Aboriginal Community Controlled Health Organisations. Selected birth outcomes were also analysed and will be reported.&#x0D; Conclusion/Implications1st Nations Governance combined with a privacy-protecting linkage model underpinned PoC ensuring strong community trust, engagement and control. It is 1st time such extensive data-linkage has been achieved demonstrating feasibility in developing a comprehensive dataset with the potential for evidence-based, targeted population health initiatives to be developed, implemented and evaluated.

Design and Implementation of a Depression Registry for Primary Care.

Registries are fundamental to the success of population health initiatives to improve care and outcomes for patients, including those with depression. The purpose of this article is to describe the design and clinical implementation of a depression registry as part of a collaborative care for depression intervention at 2 large academic outpatient internal medicine practices. The primary objective of the registry was to identify and track patients with depression and monitor antidepressant therapy. Secondary objectives of the registry were to assist in addressing pay-for-performance and value-based reimbursement metrics for depression screening and remission. The registry design and variables for inclusion in the registry were defined with input from clinicians, institutional leadership, and data analysts. For implementation, specific clinical workflows were established and responsible team roles were designated.

Let’s not blame the patient: Understanding the benefits and shortcomings of population health in orthopaedic surgery

Population health is a concept that emerged from the desire of providers to care for patients in a manner that produces the best possible outcomes while minimizing cost. It may be defined as the study of medical data of large groups of people in order to recognize and investigate patterns. This information is then used to create disease management guidelines that streamline care and regulate practice patterns. Whereas population health looks to recognize commonalities in data, the concept of patient-centered care focuses on embracing individualization and increasing the involvement of each patient within their treatment planning. Combining both perspectives creates a challenge for providers and patients to strike the proper balance between adhering to standardized guidelines based on the treatment methods and outcomes recognized in populations and applying it clinically to individual patients. A significant contribution of population health studies is the identification of risk factors associated with increased rates of complications following total joint arthroplasty as well as preventative measures for conditions such as osteoarthritis. However, to employ these findings in a patient-centered manner orthopaedic surgeons must take this a step further and also evaluate a patient’s ability to adhere to the recommendations by exploring factors such as home environment and socioeconomic factors, thus proactively addressing issues that could hinder patient compliance. With focused collection methods of acquiring data, these two practices of care will hopefully begin to see less divergence when it comes to applying data derived from population health initiatives to individual patients in a patient-centered manner.