Population Health Management

Question 1

Define population health

Answer 1

the health outcomes of a group of individuals, including the distribution of such outcomes within the group - look at patterns of determinants and outcomes and qaulity; direct policy and research agendas
no one in the public or private sector currently has responsibility for overall health improvement

Question 2

Population health is NOT just the overall health of a population, but also includes

Answer 2

the distribution of health
overall health could be quite high if the majority of the population is relatively healthy, even though a minority of the population is much less healthy

Question 3

Health is defined not simply as a state free from disease but as,

Answer 3

the capacity of people to adapt to, respond to, or control life’s challenges and changes
greater focus on SDOH

Question 4

Goals of population health

Answer 4

set targets for overall population; maintain and improve health of entire population; eliminate or significantly reduce deficiencies and disparitites between subgroups

Question 5

Access to health services by family income

Answer 5

poor or near poor had no target met/exceeded for health outcomes
higher the outcome –> more likely the targets are met

Question 6

Healthy people 2030

Answer 6

sets data driven national objectives (355) to improve the health and well-being over the next decade

Question 7

Healthy people 2030 objectives grouped by

Answer 7

health conditions
health behaviors
populations
settings + systems
SDOH: economics stability, education access and quality, health care access and quality, neighborhood and built envrionment, social and community context

Question 8

COVID19 revealed

Answer 8

inadequecies in our public health system

Question 9

Differentiate population health from public health

Answer 9

traditionally, public health has been understood by many to be the critical functions of state and local public health departments such as preventing epidemics, containing environmental hazards, and encouraging healthy behaviors
much of the US public health activity does not have such a broad mandate even in its assurance functions, since major population health determinants like health care, education, and income remain outside public health authority and responsibility
current resources provide inadequate support for traditional, let alone emerging, public health functions

Question 10

Describe how population health differs from healthcare for individual patients

Answer 10

source of potential conflict: self interest of the individual vs the common good

Question 11

List examples of different patient populations

Answer 11

Types of groups in healthy people 2030: adolescents/children/infants/older adults; LGBTQ; parents/care givers; men/women; people with disabilities; workforce
health outcomes of such groups are of relevance to policy makers and payers in both the public and private sectors: $$$ and productivity (healthier a pop is, more productive they’ll be)

Question 12

List potential outcomes associated with population health initiatives

Answer 12

life expectancy; mortality - infant, maternal; premature death
cost burden, access to care, quality of life/care indicators, unhealthy days, percentage reporting fair or poor health, percentage reporting mentally unhealthy

Question 13

USA ranking for life expectancy

Answer 13

45th
life expectancy is 77 yo
infant mortality: 5.8
maternal mortality: 10
even though we spend the most on HC compared to anyone else

Question 14

Females vs males life expectancy

Answer 14

females have a greater life expectancy than males

Question 15

Life expectancy at birth, by hispanic origin and race

Answer 15

greatest life expectancy: non-hispanic asian –> hispanic –> non-hispanic white –> non-hispanic black –> non-hispanic american indian/alaska native

Question 16

Leading cause of death in US

Answer 16

heart disease

Question 17

Leading cause of child death in US

Answer 17

firearms

Question 18

Describe the basic foundations of population health and discuss the possible role of pharmacists in each

Answer 18

1. descriptive epidemiology: the health of populations
2. etiology, benefits, and harms - health research evaluation
3. evidence based practice
4. implementation of health promotion and disease prevention interventions
5. determinants of health
6. population health informatics
7. evaluation

Question 19

Descriptive epidemiology: the health of populations

Answer 19

burden, course, and distribution of disease/injury

Question 20

Etiology, benefits, and harms - health research evaluation

Answer 20

comparative effectiveness research: aims to produce the type of evidence that will assist all partied to make informed decisions to improve health care at both the individual and population levels

Question 21

Evidence based practice

Answer 21

assessing the evidence using nationally recognized guidelines

Question 22

Implementation of health promotion and disease prevention interventions

Answer 22

target audience for direct interventions

Question 23

Determinants of health

Answer 23

impact of social factors on individual behaviors - income, education, employment

Question 24

Population health informatics

Answer 24

collection of population health data to assess population health, guide the provision of healthcare services and analyze health outcomes

Question 25

Evaluation

Answer 25

process, quality, and outcome assessments; decision analysis; quality improvement processes

Question 26

What makes examining population health possible

Answer 26

data

Question 27

Types of healthcare data important for population health data

Answer 27

claims data, electronic health record data, socioeconomic data, patient-generated health data, prescription and medication adherence data

Question 28

Claims data

Answer 28

easy to obtain; standardized; diagnosis codes

Question 29

Electronic health record data

Answer 29

provides clinical clues; ease of grouping patients

Question 30

Socioeconomic data

Answer 30

not frequently linked with EHR data

Question 31

Patient-generated health data

Answer 31

satisfaction surveys; patient reported outcomes

Question 32

Prescription and medicaiton adherence data

Answer 32

EHR and claims data

Question 33

What is population health management

Answer 33

optimizes health outcomes for a specific segment of a population; segment can be any group sharing a characteristic: location, income, age, illness
population health management goals/benefits: preventive health, manage chronic disease, recude HC costs

Question 34

Population health conceptual framework

Answer 34

population health management program strives to address health needs at all points along the continuum of health and well-being through participation of, engagement with, and targeted interventions for the population

Question 35

Goal of population health conceptual framework

Answer 35

maintain or improve the physical and psychosocial well-being of individuals through cost-effective tailored health solutions