Population Health Management Initiatives Research Articles

Disentangling Population Health Management Initiatives in Diabetes Care: A Scoping Review.

Population Health Management (PHM) focusses on keeping the whole population as healthy as possible. As such, it could be a promising approach for long-term health improvement in type 2 diabetes. This scoping review aimed to examine the extent to which and how PHM is used in the care for people with type 2 diabetes. PubMed, Web of Science, and Embase were searched between January 2000 and September 2021 for papers on self-reported PHM initiatives for type 2 diabetes. Eligible initiatives were described using the analytical framework for PHM. In total, 25 studies regarding 18 PHM initiatives for type 2 diabetes populations were included. There is considerable variation in whether and how the PHM steps are operationalized in existing PHM initiatives. Population identification, impact evaluation, and quality improvement processes were generally part of the PHM initiatives. Triple Aim assessment and risk stratification actions were scarce or explained in little detail. Moreover, cross-sector integration is key in PHM but scarce in practice. Operationalization of PHM in practice is limited compared to the PHM steps described in the analytical framework. Extended risk stratification and integration efforts would contribute to whole-person care and further health improvements within the population.

Program managers’ perspectives on using knowledge to support population health management initiatives in their development towards health and wellbeing systems: a qualitative study

BackgroundPopulation health management (PHM) initiatives are more frequently implemented as a means to tackle the growing pressure on healthcare systems in Western countries. These initiatives aim to transform healthcare systems into sustainable health and wellbeing systems. International studies have already identified guiding principles to aid this development. However, translating this knowledge to action remains a challenge. To help address this challenge, the study aims to identify program managers’ experiences and their expectations as to the use of this knowledge to support the development process of PHM initiatives.MethodsSemi-structured interviews were held with program managers of ten Dutch PHM initiatives. These Dutch PHM initiatives were all part of a reflexive evaluation study and were selected on the basis of their variety in focus and involved stakeholders. Program managers were asked about their experiences with, and expectations towards, knowledge use to support the development of their initiative. The interviews with the program managers were coded and clustered thematically.ResultsThree lessons for knowledge use for the development of PHM initiatives were identified: (1) being able to use knowledge regarding the complexity of PHM development requires (external) expertise regarding PHM development and knowledge about the local situation regarding these themes; (2) the dissemination of knowledge about strategies for PHM development requires better guidance for action, by providing more practical examples of actions and consequences; (3) a collective learning process within the PHM initiative is needed to support knowledge being successfully used for action.ConclusionsDisseminating and using knowledge to aid PHM initiatives is complex due to the complexity of the PHM development itself, and the different contextual factors affecting knowledge use in this development. The findings in this study suggest that for empirical knowledge to support PHM development, tailoring knowledge to only program managers’ use might be insufficient to support the initiatives’ development, as urgency for change amongst the other involved stakeholders is needed to translate knowledge to action. Therefore, including more partners of the initiatives in knowledge dissemination and mobilization processes is advised.

Implementation of an integrated community approach in deprived neighbourhoods: a theory-based process evaluation using the Consolidated Framework for Implementation Research (CFIR).

We investigated the implementation process of an Integrated Community Approach (ICA) applied in four low socio-economic status neighbourhoods in Maastricht, the Netherlands. The ICA is a Population Health Management initiative and aims to improve population health, quality of care, professional's satisfaction and decrease costs of care. This study addresses the facilitators and barriers for implementing the ICA from a stakeholder perspective, including steering group members, professionals and citizens. We conducted a mixed-methods study using a triangulation of methods to investigate the implementation from 1 December 2016 to 31 December 2020. The Consolidated Framework for Implementation Research guided data collection and data-analysis for evaluating the implementation process. In total, 77 interviews, 97 observations, seven focus groups, 65 collected documents and two surveys with open-ended questions were conducted. Facilitators for implementation were the use of citizen science to bring residents' needs into sharp focus, the integration of the ideology of Positive Health into the working routines of the professionals and leadership at the steering group level to overcome barriers in the ICA. The existing accounting and financial infrastructure obstructed combining budgets at neighbourhood level. Engaging citizens and professionals at an early stage is an important facilitator for implementation. The use of a shared vision on health also worked as a facilitator since it created a shared language among professionals, which is important in Population Health Management initiatives where multiple professionals are expected to collaborate. NTR 6543; registration date, 25 July 2017.

Transforming towards sustainable health and wellbeing systems - Eight guiding principles based on the experiences of nine Dutch Population Health Management initiatives

IntroductionPopulation Health management (PHM) initiatives are increasingly introduced, aiming to transform towards sustainable health and wellbeing systems. However, the initiatives are struggling with this development. In order to be able to act upon the complexity of such system change, understanding which strategies to implement at which moment of the development would be valuable. Based on the experiences of nine Dutch PHM initiatives, this study provides guiding principles with insights into which strategies to use, why, and when.Methods We used the realist evaluation approach for understanding the relationships between context, mechanisms and outcomes when PHM strategies were implemented. Data was based on quarterly updates of PHM developments and three interview rounds between 2014 and 2017 with different stakeholders of the Dutch PHM initiatives from health care, social care, public health, community , education, and business (n=207). Strategy-context-mechanism- outcome configurations were coded and clustered within the Collaborative Adaptive Health Network (CAHN) framework into guiding principles for PHM development.Results Based on the different experiences in PHM development across the Dutch cases, eight guiding principles for PHM development were identified, focusing on: 1. Shared commitment for a PHM-vision; 2. Mutual understanding and trust; 3. Accountability; 4. Aligning politics and policy; 5. Financial incentives; 6. A learning cycle based on a data-infrastructure; 7. Community input and involvement; and 8. Stakeholder representation and leadership. DiscussionsThe eight guiding principles are in line with the themes within international literature, and additionally provide detailed knowledge in the links between strategies, the contexts they are implemented in, the mechanisms that are triggered and its’ outcomes. Furthermore this study gained insights in which guiding principles are especially relevant during the first phases of development.Conclusion Developing to sustainable health and wellbeing systems is experienced as complex and time-consuming. The success of this development is influenced by the implementation of all the eight guiding principles, as well as applying the right strategies at the right moment in the development. Lessons learned• PHM initiatives vary in their development progress due to different strategies used.• Eight guiding principles reveal when, why and how to implement strategies.• Commitment, trust and leadership are of main importance in first development phases.LimitationsAs the current PHM initiatives have not yet fully developed towards sustainable health and wellbeing systems, the guiding principles provide insights in the first phases of development. Several international PHM initiatives are further developed and hereby provide a relevant base for future research in uncovering the suitable strategies in these contexts.Suggestions for future researchIn this study mainly experiences from CEO level representatives are retrieved. Little insights have been retrieved from health-care and care professionals or citizens themselves. Based on the experiences in this study and international literature, we expect that for further development of the PHM initiatives delegated leadership is of high relevance. Therefore additional understanding of the experiences of the health and care professionals and citizens will be valuable.

Social and demographic characteristics of frequent or high-charge emergency department users: A quantile regression application.

Heavy users of the emergency department (ED) are a heterogeneous population. Few studies have captured the social and demographic complexity of patients with the largest burden of ED use. Our objective was to model associations between social and demographic patient characteristics and quantiles of the distributions of ED use, defined as frequent and high-charge. We conducted a cross-sectional analysis of electronic health and billing records of 99 637 adults residing in an urban North Carolina county who visited an ED within Atrium Health, a large integrated health care system, in 2017. Mid-quantile and standard quantile regression models were used for count and continuous responses, respectively. Frequent and high-charge use outcomes were defined as the median (0.50) and upper quantiles (0.75, 0.95, 0.99) of the outcome distributions for total billed ED visits and associated charges during the study period. Patient characteristic predictors were: insurance coverage (Medicaid, Medicare, private, uninsured), total visits to ambulatory care during the study period (0, 1, >1), and patient demographics: age, gender, race, ethnicity, and living in an underprivileged community called a public health priority area (PHPA). Results showed heterogeneous relationships that were stronger at higher quantiles. Having Medicaid or Medicare insurance was positively associated with ED visits and ED charges at most quantiles. Racial and geographic disparities were observed. Black patients had more ED visits and lower ED charges than their White counterparts at most quantiles of the outcome distributions. Patients living in PHPAs, had lower charges than their counterparts at the median but higher charges at the 0.95 and 0.99 quantiles. The relationships between patient characteristics and frequent and high-charge use of the ED vary based on the level of use. These findings can be used to inform targeted interventions, tailored policy, and population health management initiatives.

Identifying and understanding determinants of high healthcare costs for breast cancer: a quantile regression machine learning approach

BackgroundTo identify and rank the importance of key determinants of high medical expenses among breast cancer patients and to understand the underlying effects of these determinants.MethodsThe Oncology Care Model (OCM) developed by the Center for Medicare & Medicaid Innovation were used. The OCM data provided to Mount Sinai on 2938 breast-cancer episodes included both baseline periods and three performance periods between Jan 1, 2012 and Jan 1, 2018. We included 11 variables representing information on treatment, demography and socio-economics status, in addition to episode expenditures. OCM data were collected from participating practices and payers. We applied a principled variable selection algorithm using a flexible tree-based machine learning technique, Quantile Regression Forests.ResultsWe found that the use of chemotherapy drugs (versus hormonal therapy) and interval of days without chemotherapy predominantly affected medical expenses among high-cost breast cancer patients. The second-tier major determinants were comorbidities and age. Receipt of surgery or radiation, geographically adjusted relative cost and insurance type were also identified as important high-cost drivers. These factors had disproportionally larger effects upon the high-cost patients.ConclusionsData-driven machine learning methods provide insights into the underlying web of factors driving up the costs for breast cancer care management. Results from our study may help inform population health management initiatives and allow policymakers to develop tailored interventions to meet the needs of those high-cost patients and to avoid waste of scarce resource.

Improving Technology‐Driven Patient Care Coordination: Toward a Techne for Community‐Based Organization Involvement

Health‐care systems increasingly collect and aggregate patient data from electronic medical record systems to aid in their decision making. Community‐based organizations that support patients' health and well‐being have been left behind in the development and use of technologies for coordinating patient care, despite policies that encourage cross‐sector coordination. This article presents the author's work as a rhetorician on a community‐engaged action research project to seek grant funding and health‐care partners to implement a tool that enables community‐based organization professionals to connect to health‐care providers to coordinate care for under‐resourced older adult patients. The team's practices from the project are used to inform a techne, or set of rhetorical strategies, for community‐based organizations to participate in population health management initiatives. Understanding these strategies as a techne to train other community‐based organizations to participate in cross‐sector initiatives may be critical to effectuating the goals of the Affordable Care Act and other health policies that seek to improve population‐level health outcomes.

Transforming towards sustainable health and wellbeing systems: Eight guiding principles based on the experiences of nine Dutch Population Health Management initiatives

IntroductionPopulation Health Management initiatives are increasingly introduced, aiming to develop towards sustainable health and wellbeing systems. Yet, little is known about which strategies to implement during this development. This study provides insights into which strategies are used, why, and when, based on the experiences of nine Dutch Population Health Management initiatives. MethodsThe realist evaluation approach was used to gain an understanding of the relationships between context, mechanisms and outcomes when Population Health Management strategies were implemented. Data were retrieved from three interview rounds (n = 207) in 2014, 2016 and 2017. Data was clustered into guiding principles, underpinned with strategy-context-mechanism-outcome configurations. ResultsThe Dutch initiatives experienced different developments, varying between immediate large-scale collaborations with eventual relapse, and incremental growth towards cross-sector collaboration. Eight guiding principles for development towards health and wellbeing systems were identified, focusing on: 1. Shared commitment for a Population Health Management-vision; 2. Mutual understanding and trust; 3. Accountability; 4. Aligning politics and policy; 5. Financial incentives; 6. A learning cycle based on a data-infrastructure; 7. Community input and involvement; and 8. Stakeholder representation and leadership. ConclusionDevelopment towards a sustainable health and wellbeing system is complex and time-consuming. Its success not only depends on the implementation of all eight guiding principles, but is also influenced by applying the right strategies at the right moment in the development.

How executives\u2019 expectations and experiences shape population health management strategies

BackgroundWithin Population Health Management (PHM) initiatives, stakeholders from various sectors apply PHM strategies, via which services are reorganised and integrated in order to improve population health and quality of care while reducing cost growth. This study unravelled how stakeholders’ expectations and prior experiences influenced stakeholders intended PHM strategies.MethodsThis study used realist principles. Nine Dutch PHM initiatives participated. Seventy stakeholders (mainly executive level) from seven different stakeholder groups (healthcare insurers, hospitals, primary care groups, municipalities, patient representative organisations, regional businesses and program managers of the PHM initiatives) were interviewed. Associations between expectations, prior experiences and intended strategies of the various stakeholder groups were identified through analyses of the interviews.ResultsStakeholders’ expectations, their underlying explanations and intended strategies could be categorized into four themes: 1. Regional collaboration; 2. Governance structures and stakeholder roles; 3. Regional learning environments, and 4. Financial and regulative conditions. Stakeholders agreed on the long-term expectations of PHM development. Differences in short- and middle-term expectations, and prior experiences were identified between stakeholder groups and within the stakeholder group healthcare insurers. These differences influenced stakeholders’ intended strategies. For instance, healthcare insurers that intended to stay close to the business of care had encountered barriers in pushing PHM e.g. lack of data insight, and expected that staying in control of the purchasing process was the best way to achieve value for money. Healthcare insurers that were more keen to invest in experiments with data-technology, new forms of payment and accountability had encountered positive experiences in establishing regional responsibility and expected this to be a strong driver for establishing improvements in regional health and a vital and economic competitive region.ConclusionThis is the first study that revealed insight into the differences and similarities between stakeholder groups’ expectations, experiences and intended strategies. These insights can be used to improve the pivotal cooperation within and between stakeholder groups for PHM.

Barriers to payment reform: Experiences from nine Dutch population health management sites

Population health management (PHM) initiatives aim for better population health, quality of care and reduction of expenditure growth by integrating and optimizing services across domains. Reforms shifting payment of providers from traditional fee-for-service towards value-based payment models may support PHM. We aimed to gain insight into payment reform in nine Dutch PHM sites. Specifically, we investigated 1) the type of payment models implemented, and 2) the experienced barriers towards payment reform. Between October 2016 and February 2017, we conducted 36 (semi-)structured interviews with program managers, hospitals, insurers and primary care representatives of the sites. We addressed the structure of payment models and barriers to payment reform in general. After three years of PHM, we found that four shared savings models for pharmaceutical care and five extensions of existing (bundled) payment models adding providers into the model were implemented. Interviewees stated that reluctance to shift financial accountability to providers was partly due to information asymmetry, a lack of trust and conflicting incentives between providers and insurers, and last but not least a lack of a sense of urgency. Small steps to payment reform have been taken in the Dutch PHM sites, which is in line with other international PHM initiatives. While acknowledging the autonomy of PHM sites, governmental stewardship (e.g. long-term vision, supporting knowledge development) can further stimulate value-based payment reforms.

Predictors of MRI Leakage Among Patients Attributed to an Academic Medical Center Commercial Risk-Shared Insurance Contract

PurposeFor health care organizations engaged in risk-shared insurance contracts, leakage of advanced diagnostic imaging to imaging sites not affiliated with the risk-sharing organization may undermine performance on financial and quality metrics. The goal of this study was to identify factors that are predictive of leakage of MRI examinations among patients attributed to an academic health care organization’s risk-shared commercial insurance contract. MethodsAdministrative claims data from 2015 through 2016 for patients attributed to a single risk-shared commercial insurance contract at a large academic medical center (AMC) were analyzed. Primary outcome was MRI leakage: an outpatient MRI study performed at a site not affiliated with the AMC’s integrated health care system. Ordering provider alignment with the AMC’s risk-shared insurance contract was categorized as strong, weak, or none. Multivariate regression analyses were conducted to evaluate the relationship between provider alignment and MRI leakage, while adjusting for selected covariates. ResultsAmong 8,215 patients meeting inclusion criteria, there were 13,272 MRI encounters. The overall proportion of leaked MRI studies was 12.7%. MRI studies ordered by providers with weak AMC alignment (odds ratio, 3.16; 95% confidence interval, 2.49-4.02) or no AMC alignment (odds ratio, 3.68; 95% confidence interval, 3.12-4.33) were more likely to leak than MRI studies ordered by providers with strong AMC alignment. ConclusionsAn ordering provider with no alignment with an AMC’s commercial risk-shared insurance contract was the strongest predictor of MRI leakage. Population health management initiatives aimed at reducing leakage should consider the impact of provider networks and clinical referral patterns that drive imaging utilization.

2018 Health Care & Education Presidential Address: The American Diabetes Association in the Era of Health Care Transformation.

This address was delivered by Felicia Hill-Briggs, PhD, ABPP, President, Health Care & Education of the American Diabetes Association (ADA) at the ADA’s 78th Scientific Sessions in Orlando, FL, on 23 June 2018. Diabetes has become a high-priority condition in the current era of health care transformation due to diabetes and prediabetes prevalence rates, suboptimal diabetes outcomes at the health care system and population levels, and high health care and public health costs attributed to diabetes. Population health is the path forward for the ADA to facilitate diabetes health care and public health improvement nationally. Population health management initiatives underway at the ADA include Diabetes INSIDE for health care systems and a Mental Health Provider Training Program and referral directory. Population health improvement initiatives include the prediabetes Risk Test Campaign, National Diabetes Prevention Program (DPP) dissemination in underserved states and populations, a DPP Express information technology platform, and a social determinants of health scientific review and recommendations. Dr. Hill-Briggs is a professor of medicine; physical medicine and rehabilitation; health, behavior, and society; and acute and chronic care at Johns Hopkins University in Baltimore, MD. She is a core faculty member of the Welch Center for Prevention, Epidemiology & Clinical Research and colead of behavioral, social, and systems science for the Johns Hopkins Institute for Clinical and Translational Research. Dr. Hill-Briggs has been elected to the National Academy of Medicine of The National Academies of Science, Engineering, and Medicine and is the 2018 recipient of the Rachmiel Levine Medal for Leadership from the ADA.

The American Diabetes Association in the Era of Health Care Transformation.

This address was delivered by Felicia Hill-Briggs, PhD, ABPP, President, Health Care & Education of the American Diabetes Association (ADA) at the ADA’s 78th Scientific Sessions in Orlando, Fla., on 23 June 2018. Diabetes has become a high-priority condition in the current era of health care transformation due to diabetes and prediabetes prevalence rates, suboptimal diabetes outcomes at the health care system and population levels, and high health care and public health costs attributed to diabetes. Population health is the path forward for the ADA to facilitate diabetes health care and public health improvement nationally. Population health management initiatives underway at the ADA include Diabetes INSIDE for health care systems and a Mental Health Provider Training Program and referral directory. Population health improvement initiatives include the prediabetes Risk Test Campaign, National Diabetes Prevention Program (DPP) dissemination in underserved states and populations, a DPP Express information technology platform, and a social determinants of health scientific review and recommendations. Dr. Hill-Briggs is a professor of medicine; physical medicine and rehabilitation; health, behavior, and society; and acute and chronic care at Johns Hopkins University in Baltimore, Md. She is a core faculty member of the Welch Center for Prevention, Epidemiology & Clinical Research and co-lead of behavioral, social, and systems science for the Johns Hopkins Institute for Clinical and Translational Research. Dr. Hill-Briggs has been elected to the National Academy of Medicine of The National Academies of Science, Engineering, and Medicine and is the 2018 recipient of the Rachmiel Levine Medal for Leadership from the ADA.

Did Performing Community Health Needs Assessments Increase Community Health Program Spending by North Carolina's Tax-Exempt Hospitals?

As of March 23, 2012, the Internal Revenue Service (IRS) requires tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every 3 years. This study assessed whether the IRS CHNA mandate incentivized North Carolina's tax-exempt hospitals to increase investments in community health programs. The authors gathered the 2012-2016 community benefit reports of 53 North Carolina private, nonprofit hospitals from the North Carolina Hospital Association. Community benefit spending data from the year of the first CHNA were compared to that 2 years later using paired t tests among matched subjects. No significant increases were found in hospitals' community health programs spending (P = 0.6920) or in providing patient care financial assistance (charity or discounted care) (P = 0.0934). In fact, aggregate community health programs spending effectively decreased by 4%, from $393.3 million to $377.5 million. Among all community benefit items, only the unreimbursed cost for treating Medicare patients increased significantly (P = 0.0297). The proportion of spending on community health programs relative to patient care financial assistance decreased significantly (P = 0.0338). Performing CHNAs did not incentivize North Carolina's tax-exempt hospitals to progressively invest in community health programs. The hospitals continue to spend heavily on patient care financial assistance and little on disease prevention and community health improvement activities. These findings suggest that tax-exempt hospitals continue to function as a safety net for the poor and the uninsured rather than as active partners in population health management initiatives. At present, performing CHNAs may be more a demonstration of compliance than a tool to improve population health.

How to Measure Population Health: An Exploration Toward an Integration of Valid and Reliable Instruments.

Population health management initiatives are introduced to transform health and community services by implementing interventions that combine various services and address the continuum of health and well-being of populations. Insight is required into a population's health to evaluate implementation of these initiatives. This study aims to determine the performance of commonly used instruments for measuring a population's experienced health and explores the assessed concepts of population health. Survey-based Short Form 12, version 2 (SF12, health status), Patient Activation Measure 13 (PAM13), and Kessler 10 (K10, psychological distress) data of 3120 respondents was used. Floor/ceiling effects were studied using descriptive statistics. Validity was assessed using factor and discriminant analyses, and reliability was assessed using Cronbach α. Finally, to study covered concepts, exploratory factor analyses (EFAs) were conducted, which included additional surveyed characteristics. The SF12 and PAM13 sum scores showed acceptable averages and distributions, while results of the K10 indicated a floor effect. SF12 and K10 measured their expected constructs, while PAM13 did not. The EFA of PAM13 displayed 1 instead of the expected 4 constructs. Reliability was good for all instruments (α 0.89–0.93). The overall EFA identified 4 concepts: mental, physical ability, lifestyle, and self-management. SF12 and PAM13, combined with lifestyle characteristics, are shown to provide insightful information to measure the physical, mental, lifestyle, and self-management concepts of population health. Future research should include additional instruments that cover new aspects introduced by recent definitions of health.

Total Health-Related Costs Due to Absenteeism, Presenteeism, and Medical and Pharmaceutical Expenses in Japanese Employers.

Objective:This study aimed to examine a detailed breakdown of costs (absenteeism, presenteeism, and medical/pharmaceutical expenses), of the employees in four pharmaceutical companies in Japan.Methods:This is a cross-sectional study. Absenteeism and presenteeism were measured by a self-administered questionnaire for workers, and their costs were estimated using the human capital approach. Presenteeism was evaluated by the degree affected quality and quantity of work. Medical and pharmaceutical expenses were obtained by insurance claims.Results:The monetary value due to absenteeism was $520 per person per year (11%), that of presenteeism was $3055 (64%), and medical/pharmaceutical expenses were $1165 (25%). Two of the highest total cost burdens from chronic illness were related to mental (behavioral) health conditions and musculoskeletal disorders.Conclusion:A total cost approach can help employers set priorities for occupational health, safety, and population health management initiatives.

Key drivers of payment reform in population health management: lessons from nine Dutch pioneer sites

Introduction: Population health management (PHM) initiatives aim to improve health outcomes and quality of care, while slowing down cost growth (Triple Aim) for a prespecified population. In theory, a key precondition for successful PHM is to redesign provider payment schemes by shifting away from the classic fee-for-service payment system. Our objective is to gain insight in the role that payment reforms play in practice, focusing on current PHM initiatives within the nine Dutch pioneer sites. Methods: Interviews were conducted with at least two key representatives (e.g. health insurers and providers) involved in each of the nine pioneer sites. Additionally, we studied documentation published by the pioneer sites. In the interviews, we discussed 1) which alternative payments structures have been implemented (pay-for-performance, shared savings, bundled payments, capitation), 2) the key design elements of these payment structures (scope, contract duration, risk mitigation, benchmark, accountability, data need, quality indicators, financing structure), and 3) which barriers and successes have been experienced by implementing the alternative payment structures. Interviews are held during the period nov 2016 – jan 2017 and are analysed with MaxQda afterwards. Results: Preliminary results show that payment reforms seem to be implemented to some extent. As such, shared savings have been introduced, mainly in pharmacy settings. Additionally, efforts have been made to negotiate lump sum payments with hospitals to stimulate substitution towards primary care. At the ICIC 2017 conference, the final results, including the experienced barriers and successes, will be presented. Discussion and conclusion: As this study will reveal the role that payment reforms play in practice in the nine Dutch pioneer sites, it will provide useful information for policy makers who are interested in stimulating further transition in two ways. First, it may be used to anticipate on barriers that are experienced by the field. Second, successes may be extended to other sites.

Is "disease management" the answer to our problems? No! Population health management and (disease) prevention require "management of overall well-being".

BackgroundDisease management programs based on the chronic care model have achieved successful and long-term improvement in the quality of chronic care delivery and patients’ health behaviors and physical quality of life. However, such programs have not been able to maintain or improve broader self-management abilities or social well-being, which decline over time in chronically ill patients. Disease management efforts, population health management initiatives and innovative primary care solutions are still mainly focused on clinical and functional outcomes and health behaviors (e.g., smoking cessation, exercise, and diet) failing to address individuals’ overall quality of life and well-being. Individuals’ ability to achieve well-being can be assessed with great specificity through the application of social production function (SPF) theory. This theory asserts that people produce their own well-being by trying to optimize the achievement of instrumental goals (stimulation, comfort, status, behavioral confirmation, affection) that provide the means to achieve the larger, universal goals of physical and social well-being.DiscussionA shift in focus from the management of physical function, disease limitations, and lifestyle behaviors alone to an approach that fosters self-management abilities such as self-efficacy and resource investment as well as overall quality of life, is urgently needed. Disease management interventions should be aimed at adequately addressing all difficulties chronically ill patients face in life, such as the effects of pain and fatigue on the ability to maintain a job and social life and to participate in activities promoting physical and social well-being. Patients’ ability to maintain engagement in stimulating work and social activities with the people who are important to them may be even more important than aspects of disease self-management such as blood pressure or glycemic control. Interventions should aim to make chronically ill patients capable of managing their own well-being and adequately addressing their needs in a broader sense.SummarySo, is disease management the answer to our problems in the time of aging populations and increased prevalence of unhealthy lifestyles, chronic illnesses, and comorbidity? No! Effective (disease) prevention, disease management, patient-centered care, and high-quality chronic care and/or population health management calls for management of overall well-being.

Defining Population Health Management: A Scoping Review of the Literature

Population health management (PHM) has increasingly been mentioned as a concept to realize improvements in population health and quality of care while reducing cost growth (the so-called Triple Aim). The concept of PHM has been used in various settings and has been defined in different ways. This study compared the definitions of PHM used in the literature in order to improve the understanding and interpretation of the concept of PHM. A scoping literature search was performed for papers published between January 2000 and January 2015 that defined PHM. PHM definitions were summarized, focusing on: (1) overall aim, (2) PHM activities, and (3) contextual factors. Eighteen articles were retrieved. The overall aim was defined in terms of health (N = 14), costs (N = 8), and/or quality of care (N = 10). Definitions varied regarding the description of PHM activities, though all definitions contained elements in common with disease management and health promotion. Data management, Triple Aim assessment, risk stratification, evaluation, and feedback cycles were less likely to be mentioned. Contextual factors were scarcely brought forward in the definitions. Moderate variations were found across definitions in the way PHM was conceptualized. Frequently, essential elements of PHM were not specified. Differences in conceptualizations of PHM should be taken into account when comparing PHM initiatives that are working toward improvements in population health, (experienced) quality of care, and reduction of costs.

Singapore's regional health systems-a data-driven perspective on frequent admitters and cross utilization of healthcare services in three systems.

With population health management being a priority in the Singapore, this paper aims to provide a data-driven perspective of the population health management initiatives to aid program planning and serves as a baseline for evaluation of future implemented programs. A database with information on patient demographics, health services utilization, cost, diagnoses and chronic disease information from 2008 to 2013 for three regional health systems in Singapore was used for analysis. Patients with three or more inpatient admissions were considered as "Frequent Admitters." Health service utilization was quantified, and cross utilization of services was studied. One-year readmission rate for inpatients was studied, and a predictive model for readmission or death was developed. There were a total of 2.8 M patients in the database. Frequent admitters accounted for 0.9% of all patients with an average cost per patient of S$29 547. Of these, 89% had chronic diseases. Cross utilization of health services showed that 8.2% of the patients utilized services from more than one hospital with 19.6% utilizing hospital and polyclinic services in 2013. The highest risk of readmission or death was for those patients who had five or more inpatient episodes in each of the preceding 2 years. By understanding the profile of the patients and their utilization patterns in the three regional health systems, our study will help clinicians and decision makers design appropriate integrated care programs for patients with the aim of covering the healthcare needs for the enitre population across the healthcare spectrum in Singapore. Copyright © 2015 John Wiley & Sons, Ltd.