The document discusses population health management and achieving healthy communities. It outlines major issues with the US healthcare system like uneven access to care. Real reform requires a focus on prevention, continuous care relationships, and evidence-based decisions. Population health management programs aim to maintain and improve people's health across different risk levels. Barriers to population health include fragmented care and misaligned incentives. Patient-centered medical homes and accountable care organizations show promise by emphasizing coordinated, team-based care. Automation and health information technology can help strengthen these models and drive effective population health management.
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Claire Cordeaux SIMUL8 Executive Director for Health & Social Care were invited by Centers for Medicare & Medicaid Services to discuss how NHS England work in chronic disease.
Tackling Post-Ebola Health Recovery: Strengthening health system capacity to ...JSI
In late 2015, the government-mandated Comprehensive Program for Ebola Survivors (CPES) was established as part of the key interventions within the Post-Ebola
Recovery Strategy. The CPES program, sought to improve the well-being of Ebola virus disease (EVD) survivors by providing basic and specialized health care and support to recover their livelihood. Survivors were also included in the existing Free Health Care Initiative (FHCI) program, already offered to children under 5 and pregnant and lactating women. This decision aimed at allowing survivors to access the public-sector health
services without cost.
As the program developed, the MoHS recognized that many of the health issues facing EVD survivors, such as mental health, eye complications, etc. were also common for general population, as well as other FHCI vulnerable population groups. Changes were made to promote self-reliance and were needed to enable the integration of the CPES supported health services and human resources within the MoHS system and the EVD survivors within the FHCI.
The CPES program worked to respond to survivor needs and restore EVD survivors’confidence in a country health system that was heavily disrupted by the Ebola outbreak; and ensure their special needs were addressed in a timely and efficient manner. 10% more survivors were able to lead a healthy functional life because of the project intervention. Moreover, there has been a 6.1% reduction in the proportion of survivors reporting some sort of stigma and a 12% drop in the proportion of those reporting stigma during their last interaction with a healthcare provider. Community support: The peer-to-peer approach implemented with the Survivor Advocates has helped reduce stigma associated with EVD and supported the rebuilding of trust between survivors, the communities, and local health facilities. However, when SAs were terminated, the transition to CHWs had not taken place.
This poster was presented at the Fifth Global Symposium on Health Systems Research in Liverpool in October by Soumya Alva.
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Claire Cordeaux SIMUL8 Executive Director for Health & Social Care were invited by Centers for Medicare & Medicaid Services to discuss how NHS England work in chronic disease.
Tackling Post-Ebola Health Recovery: Strengthening health system capacity to ...JSI
In late 2015, the government-mandated Comprehensive Program for Ebola Survivors (CPES) was established as part of the key interventions within the Post-Ebola
Recovery Strategy. The CPES program, sought to improve the well-being of Ebola virus disease (EVD) survivors by providing basic and specialized health care and support to recover their livelihood. Survivors were also included in the existing Free Health Care Initiative (FHCI) program, already offered to children under 5 and pregnant and lactating women. This decision aimed at allowing survivors to access the public-sector health
services without cost.
As the program developed, the MoHS recognized that many of the health issues facing EVD survivors, such as mental health, eye complications, etc. were also common for general population, as well as other FHCI vulnerable population groups. Changes were made to promote self-reliance and were needed to enable the integration of the CPES supported health services and human resources within the MoHS system and the EVD survivors within the FHCI.
The CPES program worked to respond to survivor needs and restore EVD survivors’confidence in a country health system that was heavily disrupted by the Ebola outbreak; and ensure their special needs were addressed in a timely and efficient manner. 10% more survivors were able to lead a healthy functional life because of the project intervention. Moreover, there has been a 6.1% reduction in the proportion of survivors reporting some sort of stigma and a 12% drop in the proportion of those reporting stigma during their last interaction with a healthcare provider. Community support: The peer-to-peer approach implemented with the Survivor Advocates has helped reduce stigma associated with EVD and supported the rebuilding of trust between survivors, the communities, and local health facilities. However, when SAs were terminated, the transition to CHWs had not taken place.
This poster was presented at the Fifth Global Symposium on Health Systems Research in Liverpool in October by Soumya Alva.
Engines of Success for U.S. Health Reform?
Eric B. Larson, MD, MPHVice President for Research, Group Health Executive Director, Group Health Research Institute
discussion on Health Economics and Health Care in our country and abroad, and what resources are given by the private sectors and with the very scarce help from the DOH, national and local government, and from the support given by WHO.
The Paradigm Shift from Healthcare to Population HealthPractical Playbook
The Practical Playbook
National Meeting 2016
www.practicalplaybook.org
Bringing Public Health and Primary Care Together: The Practical Playbook National Meeting was at the Hyatt Regency in Bethesda, MD, May 22 - 24, 2016. The meeting was a milestone event towards advancing robust collaborations that improve population health. Key stakeholders from across sectors – representing professional associations, community organizations, government agencies and academic institutions – and across the country came together at the National Meeting to help catalyze a national movement, accelerate collaborations by fostering skill development, and connect with like-minded individuals and organizations to facilitate the exchange of ideas to drive population health improvement.
The National Meeting was also a significant source of tools and resources to advance collaboration. These tools and resources are available below and include:
Session presentations and materials
Poster session content
Photos from the National Meeting
The conversation started at the National Meeting is continuing in a LinkedIn Group "Working Together for Population Health" and Twitter. Use #PPBMeeting to provide feedback on the National Meeting.
The Practical Playbook was developed by the de Beaumont Foundation, the Duke University School of Medicine Department of Community and Family Medicine, the Centers for Disease Control and Prevention (CDC), and the Health Resources & Services Administration (HRSA).
A presentation to start a workshop with community pharmacists on the contribution of pharmacy to the NHS Five Year Forward View, Health and Wellbeing Strategy and Sustainability and Transformation Plan
Validity and bias in epidemiological studyAbhijit Das
Validity and bias are essential aspects of any research—a brief description of internal and external validity and different types of bias related to the epidemiological study.
An Introduction to Health Care ManagementPreji M P
This is an Introduction to Health Tourism specialization students duly catering to the syllabus of Health care Management paper with a focus on basic anatomy and physiology.
Engines of Success for U.S. Health Reform?
Eric B. Larson, MD, MPHVice President for Research, Group Health Executive Director, Group Health Research Institute
discussion on Health Economics and Health Care in our country and abroad, and what resources are given by the private sectors and with the very scarce help from the DOH, national and local government, and from the support given by WHO.
The Paradigm Shift from Healthcare to Population HealthPractical Playbook
The Practical Playbook
National Meeting 2016
www.practicalplaybook.org
Bringing Public Health and Primary Care Together: The Practical Playbook National Meeting was at the Hyatt Regency in Bethesda, MD, May 22 - 24, 2016. The meeting was a milestone event towards advancing robust collaborations that improve population health. Key stakeholders from across sectors – representing professional associations, community organizations, government agencies and academic institutions – and across the country came together at the National Meeting to help catalyze a national movement, accelerate collaborations by fostering skill development, and connect with like-minded individuals and organizations to facilitate the exchange of ideas to drive population health improvement.
The National Meeting was also a significant source of tools and resources to advance collaboration. These tools and resources are available below and include:
Session presentations and materials
Poster session content
Photos from the National Meeting
The conversation started at the National Meeting is continuing in a LinkedIn Group "Working Together for Population Health" and Twitter. Use #PPBMeeting to provide feedback on the National Meeting.
The Practical Playbook was developed by the de Beaumont Foundation, the Duke University School of Medicine Department of Community and Family Medicine, the Centers for Disease Control and Prevention (CDC), and the Health Resources & Services Administration (HRSA).
A presentation to start a workshop with community pharmacists on the contribution of pharmacy to the NHS Five Year Forward View, Health and Wellbeing Strategy and Sustainability and Transformation Plan
Validity and bias in epidemiological studyAbhijit Das
Validity and bias are essential aspects of any research—a brief description of internal and external validity and different types of bias related to the epidemiological study.
An Introduction to Health Care ManagementPreji M P
This is an Introduction to Health Tourism specialization students duly catering to the syllabus of Health care Management paper with a focus on basic anatomy and physiology.
Advancing Team-Based Care: Complex Care Management in Primary CareCHC Connecticut
This webinar investigated the ways that team members can contribute to the care of patients with complex medical and/or social needs. The focus was on developing the expanded care team and ensuring ready communication between the core and expanded care teams. Models for effective care management were presented.
This webinar was presented May 5, 2016 3:00 p.m. Eastern Time
World Psychiatric Association - Health Systems' Performance Roundtable cana...Université de Montréal
This was part of a roundtable presentation on health systems' performance around the world, focusing on psychiatric care. My contribution was a survey of the Canadian health care system's performance.
In search of a digital health compass: My data, my decision, our powerchronaki
Knowledge is power. Despite extensive investments in digital health technology, navigating the health system online is challenging for most citizens. Also for eHealth, the “Inverse Care Law” proposed by Hart in 1971, seems to apply. Availability of good medical or social care services and tools online, varies inversely with the need of the population. The low adoption of eHealth services, and persistent disparities in health triggers a call for multidisciplinary action.
Barriers and challenges are not to be underestimated. Culture, education, skills, costs, perceptions of power and role, are essential for multidisciplinary action. This comes together in digital health literacy, which ought to become an integral part to navigate any health system. Patients living with an implanted device or coping with persistent, chronic disease such as diabetes, as well as citizens engaged in self-care, caring for an elderly relative, a neighbor, or their child with illness or deteriorating health, need a digital health compass.
The panel will engage the audience to elaborate on a vision for this personal, digital health compass and drive advancement in health informatics and digital health standards. The transformative power of health data fueled by targeted digital health literacy interventions can be leveraged by open, massive, and individualized delivery. This way, digital health literate, confident patients and citizens join health professionals, researchers and policy makers to address age-related health and wellness changes to shape the emerging precision medicine and population health initiatives.
From a panel in the eHealthweek 2016. http://www.ehealthweek.org/ehome/128630/hl7-efmi-sessions/
Patient Centered Medical home talk at WVUPaul Grundy
To employers the cost of healthcare is now a business issue and this talk is about what one large buyer IBM did to drive transformation via broad coalition with other large employers to form the Patient Centered Medical Home movement and the covenant between buyer and provider away from the garbage we now buy episodic uncoordinated disintegrated care. In the change of convenient conversation we have worked with the Primary care providers to give us coordinated, integrated, accessible and compressive care with a set of principles know as the Patient centered medical home.
A Patient Centered Medical Home (PCMH) happens when primary care healers keeping that core healing relationship with their patients step up to become specialists in Family and Community Medicine. The move is to the discipline of leading a team that delivers population health management, patent centered prevention, care that is coordination, comprehensive accessible 24/7 and integrated across a deliver system. PCMH happens when the specialists in Family and Community Medicine wake up every morning and ask the question how will my team improve the health of my community today?
All over the world three huge factors are in play that is driving the concept of Patient Centered Medical Home. They are:
1) Cost and demography
2) Information technology and data (information that is actionable will equal a demand for accountability by the payer or buyer of the care)
3) Consumer demand to engage healthcare differently (at least as well as they can their bank- on line) have a question about lab results why not e-mail?
But at its core it is a move toward integration of a healing relationship in primary care and population management all at the point of care with the tools to do just that.
Stephen Morgan, M.D.
Senior Vice President, Chief Medical Information Officer
Carilion Clinic
iHT2 case studies and presentations illustrate challenges, successes and various factors in the outcomes of numerous types of health IT implementations. They are interactive and dynamic sessions providing opportunity for dialogue, debate and exchanging ideas and best practices. This session will be presented by a thought leader in the provider, payer or government space.
Ρητορική και πολιτική στην Πρωτοβάθμια Φροντίδα. Η αναγκαιότητα μιας τεκμηριω...Evangelos Fragkoulis
Παρούσιαση μου στα πλαίσια του 13ου Health Policy Forum, με θέμα:
"Πρωτοβάθμια Φροντίδα Υγείας: Προϋποθέσεις Ανασυγκρότησης και Ανάπτυξης"
Αρχαία Ολυμπία, 15-17 Απριλίου 2016
http://www.healthpolicy.gr/13%CE%B7-%CF%83%CF%85%CE%BD%CE%AC%CE%BD%CF%84%CE%B7%CF%83%CE%B7-%CE%B1%CF%81%CF%87%CE%B1%CE%AF%CE%B1-%CE%BF%CE%BB%CF%85%CE%BC%CF%80%CE%AF%CE%B1-2016/
Dr Jeremy Veillard: High Use in the Health Sector in Canada, 30 June 2014Nuffield Trust
In this slideshow, Dr Jeremy Veillard, Vice President, Research and Analysis, Canadian Institute for Health Information, describes how data is used in Canadian health care, describing a number of data linkage projects.
Dr Jeremy Veillard spoke at the Nuffield Trust event: The future of the hospital, in June 2014.
Moving toward universal health coverage of Indonesia: where is the position?Ahmad Fuady
My final thesis about the Indonesian movement towards universal health coverage and its achievement in providing the right to health for Indonesian people.
1. Population Health –
The Myths and Realities of
Achieving a Healthy Community
Lancaster General Hospital
November 17, 2011
Steven Peskin, MD, MBA, FACP
EVP and Chief Medical Officer, MediMedia
Associate Clinical Professor of Medicine, UMDNJ
3. Major Issues with the US Healthcare System
• Poor and uneven access to medical care, especially for
the uninsured
• Escalating costs and volume of services
• No link between cost and quality
• Excessive administrative costs
• Dysfunctional payment system
• United States is lagging internationally in health outcomes
4. Real Reform: Real Leadership
1. The missing link is links!
2. Comparative outcomes are all relevant and
visible to patients.
3. Many treat, few prevent.
4. Create a culture of health.
5. Real Reform: Real Leadership
Current Approach New Approach
---------------------------------------------- ----------------------------------------------
Focus on current medical problem Focus on all risks
Primary care physicians Cooperative team of providers
Care based on periodic visit Continuous healing relationships
Short visits with little information Emphasis on education & coaching
Decisions by clinical autonomy Evidence-based decisions
Information restricted Electronic information flows freely
One size fits all Care customized to needs & values
Patient a passive participant Patient/family active participants
6. The Concept of Population Health Management
• PHM programs are a set of interventions designed to
maintain and improve people’s health across the full
continuum of care
–from low-risk, healthy individuals to high-risk individuals with
one or more chronic conditions.
• Populations targeted by PHM are often delineated by
health benefit source rather than geography. However,
some proponents argue that because improving
population health is a national goal, a target population
can also be identified broadly, as in “all citizens of the
United States,” as well as narrowly, as in “all people who
call Dr. Jones their doctor” (Berwick et al. 2008).
6
8. The Conceptual Framework
Population health is person-centered; organizational
interventions are tailored to the individual and community
resources are targeted to individuals. Individuals are
evaluated to identify their place on a continuum of health
risks, from no or low risk to high risk. Specific
interventions, such as health promotion and wellness, risk
management, care coordination/advocacy, and
disease/case management, are targeted to people based
on where they fall on the continuum of risk/care.
8
9. Aspects of PHM Cont’d
• Patient self-management education
• Focus on health behavior and lifestyle changes
• Interoperable electronic health records
• Electronic registries
9
12. 2011 Snapshot
comparison of
Lancaster County
vs. the MOST
HEALTHY
(CHESTER) and
the LEAST
HEALTHY County
(Philadelphia)
County in PA
when comparing
Health Factors
12
13. 2011 Snapshot
comparison of
Lancaster County
vs. the MOST
HEALTHY
(UNION) and the
LEAST HEALTHY
County
(Philadelphia)
County in PA
when comparing
Health Outcomes
13
14. Population health engagement – menu of options
• Worksite
• Physician’s Office
• Hospital
Screenings • Other Clinical Facility
• At Home
• Lab option
Target • Telephonic Health Coaching
addressing lifestyle and chronic
Programs conditions
• Mail based programs
• Onsite programs
• Communications
• E-messaging
Population • Online Programs
Programs • Campaigns
• Warm transfers/ HA
• Health Plans
Referrals • Employers
• Physician’s
• Other Providers 14
15. The Three Pillars of Engagement
15
Source - Staywell Health Management 2011
16. Obstacles to PHM
In the U.S., the biggest barriers to
population health management are:
• Fragmentation of care delivery
• Misaligned financial incentives
• Lack of managed care knowledge
• Insufficient use of health information technology
16
17. Three Pillars of PHM
• To execute on the promise of PHM, physicians and their care teams
must strengthen their relationships with patients in a variety of
ways, including making sure they come in for needed preventive and
chronic care. Care teams, which include physicians, midlevel
practitioners, medical assistants, and nurse educators, must
optimize the services they provide to patients during office visits.
And as a coordinated team, they must extend their reach beyond
the four walls of the office to provide a continuous healing
relationship. The appropriate IT tools can facilitate achievement of
all three goals while lessening the burden on practices.
17
18. The Beginnings of Change
• Over the past 15 or 20 years, approaches such
as pay for performance and disease
management have had a limited effect on quality
improvement.
• More promising models have emerged in the
past few years. These include:
– Patient-centered medical home (PCMH)
– Accountable care organization (ACO).
18
19. Patient Centered Medical Homes
• While much progress is being made on the PCMH, practices that try
to become medical homes can encounter obstacles.
– Small primary-care practices may lack the time and the resources to
transform themselves and acquire the necessary information technology
(Nutting, Miller, et al.).
– They may find it difficult to gain the cooperation of specialists and
hospitals.
– Physicians may not receive adequate financial support from payers for
coordinating care (Landon, Gill,et al.).
19
20. Accountable Care Organizations
• ACOs consist of hospitals and physicians that take
collective responsibility for the cost and quality of care for
all patients in their population.
• ACOs may be single business entities, such as a group-
model HMO or an integrated delivery system. But they
could also involve an “extended medical staff” or a
contracting network that includes a healthcare system.
• Core of ACO’s may be medical homes
• ? The future of population health management
20
21. The Promise of Population Health Management:
Crucial Role of Automation
• What is also needed for successful PHM is an electronic
infrastructure that performs much of the routine, time-
and labor-intensive work in the background for
physicians and their staffs. Tools exist but are
underused.
• Technology is not a substitute for the physician-patient
relationship. But to the extent that automation tools are
used to strengthen that relationship, technology can help
drive population health management.
21
22. The Promise of Population Health Management:
Crucial Role of Automation
• In order to be able to effectively manage all aspects of health from wellness
to complex care, healthcare organizations must assess the entire
population, taking advantage of online or web-based programs.
• Patients can then be stratified into various stages across the spectrum of
health.
– Those who are well need to stay well by getting preventive tests completed
– Those who have health risks need to change their health behaviors so they don’t
develop the conditions they’re at risk for
– Those who have chronic conditions need to prevent further complications by
closing care gaps and also working on health behaviors.
• Technology can be very helpful in assessing and stratifying patients and
targeting interventions to the right people. The automation of the processes
provides a more efficient and effective way to do population health
management.
22
Editor's Notes
Patient self-management education. With the help of printed and online materials, care teams help patients learn how to manage their own conditions to the extent possible.Focus on health behavior and lifestyle changes. Providers and the educational materials offered can reinforce the need for healthy lifestyles across the population.Interoperable electronic health records. EHRs are used to store and retrieve data, not only on individual patients, but on the status of the population. They are also used to track orders, referrals, and other care processes to ensure patients receive the care they need. And by exchanging data with other clinical systems, interoperable EHRs provide physicians with information that help them make better decisions.Electronic registries. Whether or not registries are part of EHRs, they are important components of PHM, because they enable caregivers to track and manage all of the services provided to or due for their patient population, as well as subgroups of that population.
Nurseline – 24/7Private labeled, toll-free serviceURAC accredited call centerWelcome call to every householdCustomized scriptingBilingual specialistsMore than150 additional languages servedTriage calls diverted to lower cost optionsDigital recording of all calls
The widespread development of ACOs, perhaps with medical homes at their core, would provide a powerful impetus for a shift from the current care delivery model to PHM. With the backing of large organizations and the introduction of financial incentives that encouraged an outcomes-oriented, patient-centered care model, PHM could become the dominant model of healthcare.To increase access to primary care, we need to make use of “disruptive innovations,” including retail clinics, employer-based wellness programs, home telemonitoring of patients with chronic conditions, and new methods of educating patients in self-management (Lawrence