Overview of Population Health:
Community Health v. Population
Health Management
September 5, 2019
Roadmap to Population Health
“
I’m on the bus for population health; in fact, I’m
driving the bus. But I need help shifting my core
business – all of which focuses on sick care – to focus
on health and well-being.”
--Hospital CEO
Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents
Agenda
1. Population health’s foundational concepts
2. Two key population paradigms
3. Activity & Discussion: Matching populations and pop health activities
to Stoto et al. (2017) four portfolios of population health framework
(handout will be provided in class)
4. Equity
Population Health’s Foundational Concepts
Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents
THINK ∙ PAIR ∙ SHARE
• What two domains were portrayed in Stout et al.’s, 2017 “Four
Portfolios of Population Health Framework?”
• What two concepts of population were described by Gourevitch
et al., 2012 (Challenge of Attribution)?
Defining
populations
Defining
health
Foundational
concepts and
goals
What is Population Health?
Population Health
Management
Community Health
(AKA TPM)
The delivery of health care
services toward the
achievement of specific
health care-related metrics
and outcomes for a
defined population…tied
to value-based contracts”
The health outcomes of
a group of individuals,
including the
distribution of such
outcomes within the
group”
Loehrer, Lewis, Bogan, 2016,
Kindig & Stoddart, 2003, AJPH
Healthcare Executive
What is Population Health?
Population Health
Management
The delivery of
health care
services toward
the achievement
of specific health
care-related
metrics and
outcomes for a
defined
population…tied
to value-based
contracts”
Loehrer, Lewis, Bogan,
2016,
Healthcare Executive
Stoto, 2014 Conceptualization
ACOs and
Population
Health
Management
Communitywide
Approaches and
CHNAs
4 Portfolios Framework, Stout et al, 2017
2 Paradigms, Gourevitch et al., 2012
Attributed/
Empaneled
patients
Place-based
populations
Community Health
(AKA TPM)
The health
outcomes of a
group of
individuals,
including the
distribution of
such outcomes
within the
group”
Kindig & Stoddart,
2003, AJPH
ACTIVITY
4 Portfolios of Population Health
What populations and activities fit in each portfolio?
Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents
Activity: Match these terms/activities to the appropriate
portfolio on prior slide
From Day 1: Defining Populations – Two Key Denominators
Empaneled Patients
Communities
Individuals attributed to a
provider or health system
based on delivery system
utilization
All persons in a given area at a
given time
Accountable Health
Total Population Health
IOM (n.d.) Working Definition of Population Health; Stoto 2013
Defined geographically or by a
shared set of characteristics
Example: Community v. Population Health Management at
MLK Jr. Community Hospital
From 3/13/2019 telelecture, Lauren Espy, MPH, Community Benefits Coordinator
Community Health v. Population Health Management
Community
Patients
Risk-stratified
targeted patients
Population Health Management
“The design, delivery,
The state and
of
coordination,
payment
of highcomplete
quality
healthcare
physical,
services to manage
mental,
and
the Triple Aim for a
social using
well-the
population
bestbeing
resources
andwe
have
available
to us
not
merely
within the health care
the absence
system”
of disease
or infirmity”
Lewis,
N., 2014,
IHI
(WHO
1994)
“The delivery
of
A resource
for
health care services
everyday life
toward the
emphasizing
achievement of
the extent
specific
healthto
carerelated
metrics
which
an and
outcomes for
individual
ora
defined
group
is
able
population…tied to
tovalue-based
realize
aspirations
contracts”
and satisfy
Loehrer,
Lewis,
Bogan, 2016,
needs”
(WHO
Healthcare Executive
1984)
“Care delivery across
patient populations to
improve clinical and
financial outcomes
through disease
management, case
management, and
demand
management”
Nelson (2012)
PHM In Practice: Risk Stratification >Tailored Interventions
5% of patients;
usually with complex
disease(s), comorbidities
HighRisk
Patients
RisingRisk Patients
Low-Risk Patients
15-35% of patients;
with two or more chronic
diseases
60-80% of patients;
with one wellmanaged condition or
no ongoing care
management needs
Intensive, proactive management,
trading high-cost acute care for lowcost complex care management
whenever clinically effective to do so
Best-in-class population health
managers strive to avoid unnecessary
spending and prevent escalation in
risk profile
Top performers strive to keep patients
healthy, maintain loyalty to system,
collect patient data for immediate
response when care needed
Adapted from The Advisory Board Company, 2014, “Answers Every Pop Health Leader Should Have”
PHM Goals
• To keep a patient population as healthy as possible,
minimizing the need for expensive interventions such
as emergency department visits, hospitalizations,
imaging tests, and procedures (Felt-List & Higgins,
2011)
• Lower costs + redefine healthcare as an activity that
encompasses more than “sick care”
• While PHM focuses partly on the high-risk patients who
generate the majority of health costs, it systematically
addresses the preventive and chronic care needs of
every patient
Which Portfolio?
Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents
Which Portfolio?
Stout et al, 2017: Pathways to Population Health: An Invitation to Health Care Change Agents
And what is at the center of the Four Portfolio model?
And what is at the center of the Four Portfolio model?
• Equity: Everyone has a fair and just opportunity to
be healthier. This requires removing obstacles to
health such as poverty, discrimination, and their
consequences, including powerlessness and the
lack of access to good jobs with fair pay, quality
education and housing, safe environments, and
health care. (RWJF)
• Health inequity: Differences in health outcomes
between groups within a population that are
systematic, avoidable, and unjust. (IHI)
Equity v. Equality
Preview: Value-based Funding Models
• Capitation: A fixed monthly pre-payment for a defined set
of services for each patient assigned to the practice (e.g.,
PMPM payment)
• Payment bundling: Link payments for the multiple
services beneficiaries received during an episode of care
• Shared savings: Incentives for providers to reduce health
care spending for a defined patient population by offering
them a percentage of net savings realized as a result of
their efforts (requires shared risk)
Revisit: Key Aspects of Population Health Management
• Organized systems of care,
made up of care teams who
coordinate care across the
continuum of care
• Risk stratification and chronic
care management
• Cross-sector collaboration
and partnerships for wellness
and prevention
• HIT, meaningful use, and
clinical integration
• Focus ‘upstream’ on social
determinants of health
• Holistic, patient-centered
primary care delivered by
interdisciplinary care teams
• Evidence-based practice
• Engaged patients
• Valid and standardized
metrics
• Risk-sharing models of care
(ACOs, medical homes)
• Accountability: No outcome,
no income (value-based
payment)
Inspiration
NEXT WEEK
Watch important social
determinants videos in class and
take in-class video quizzes!
Please arrive on time!
Turn in quizzes to TAs at end of
class.