Population Health
Kent Bottles, MD
kbottles#@pyapc.com
Summit of the Southeast 2014
Driving the Future of Healthcare T...
Population Health Definitions
• “The health outcomes of a group of
individuals, including the distribution of
such outc...
Population Health Definitions
• “A conceptual framework for why some
populations are healthier than others as well
as t...
Population Health Statistics
• The county of residence in USA means a
14-year difference in life expectancy
• On the Bl...
Population Health Statistics
• Your zip code is more important than your
genetic code for health and wellness
• College...
Population Health Statistics
• British Medical Journal- higher levels of
greenery and lower graffiti correlated with
in...
Social-Ecological Model
Individuals
Social, Family, and Community
Networks
Living and Working
Conditions
Broad Condi...
Population Health & Hospital
• Hospital-centric care model is changing to
population health management care model
based...
Population Health & Hospital
• Sharing data across all points of care is only
way to provide coordinated care
• Data ac...
Population Health Strategies
• Fitness and exercise
promotion
• Obesity management
and weight reduction
• Diet and nu...
Community- Major Site of Health Care
Green, et al., (2001) NEJM, 344:2021-25
• 1,000 adults living 1 month
• 800 report...
We Can Do Better
Steven A. Schroeder, MD, NEJM, September 20, 2007
Health is influenced by
•Genetics
•Social circumsta...
We Can Do Better
Steven A. Schroeder, MD, NEJM, September 20, 2007
• The single greatest opportunity to improve
health ...
Proportional Contribution to Premature Death
Environmental
Exposure
5%
Health Care
10%
Social Circumstances
15%
Ge...
Root Cause Analysis – Key
Drivers of Health
Driver Definition % Contribution
Behavioral Choices Diet, physical activity...
North Karelia in Finland
• Focus on nutrition, tobacco use, exercise
• Decreased heart attack deaths by 70%
• Decreased...
North Karelia in Finland
• “Stubborn persuasion.” No power.
• “What we’ve done better than the US is
we’ve managed to g...
North Karelia in Finland
• Alter local diet (from dairy and sausage to
greens “food for animals”).
• Per capita vegetab...
Stress, Loneliness, and Death
• High Stress = 57%
• High Isolation = 31%
• Both High: 20% of
Sample
– 3-fold increase...
Emotional Support and Mortality
The EPESE Cohort
Patients who reported no
emotional support had
almost three times the...
BMJ: 2005; 331: 611-612
• Higher levels of greenery, lower levels of
graffiti and litter correlated with:
– Higher leve...
Whiplash Pain and Culture
• Lithuania: no car insurance, no intractable neck
pain and lingering headaches
• Norway: car...
Social Networks & Medicine
Gina Kolata, NY Times, August 5, 2007, WK 1
• NEJM study of social network of 12,067
people ...
Why is it so hard to activate a
community to be healthy?
• Health poorly defined.
• Communities in disarray.
• Biomedi...
Population Health Requires
Providers to Deal with Strangers
• Schools
• Police
• Urban Planners
• Economic developmen...
Non-provider health influencers
• Religious entities promoting health
behavior
• Transportation facilitates access
• H...
Non-medical influencers
• Lifestyle determinants of wellness status
• Socioeconomic determinants
• Subpopulations (kids...
Dennis Weaver, MD/Adirondack
Health Institute Pilot
• Percentage of patients with BMI>95% went
from 16% to 14%
• Perce...
Mature PHM
• Organized system of care
• Care teams
• Coordination across care settings
• Access to PCP
• Patient self...
Mature PHM
• PCMH and the medical neighborhood
– Prevention
– Shift from acute to chronic care
– Predictive and proact...
Medical Neighborhood
• PCP
• Specialists
• Hospitals
• Rehab and long term care
• Home health agencies
• Pharmacies ...
Patient engagement
• Judith Hibbard’s Patient Activation
Measure 4 level scale
• Self-management
• Collaboration with ...
Patient engagement
• Jessie Gruman’s Center for Advancing
Health- 43 engagement behaviors organized
in 10 categories
Patient engagement
10 Categories
• Find safe care
• Talk to providers
• Organize health care
• Pay for health care
•...
Jessie Gruman on Patients
• As a savvy and confident patient who is
flummoxed by so much of what takes place
in health ...
Jessie Gruman on Patients
• You are immersed in the health culture. But
we don’t live in your world. So we have no
idea...
Role of HIT in PHM
• Identify and track cohorts of patients
– By risk level
– By adherence to care plans
– By medicati...
Role of HIT in PHM
• Profiling the population
• Point of Care
• Patient engagement and managment
Role of HIT in PHM
• Profiling the population
– Patient registries
– Advanced population predictive analytics
– Risk s...
Role of HIT in PHM
• Point of care
– EHR
– Health information exchange
– Referral tracking
Role of HIT in PHM
• Patient activation and management
– Automated outreach
– Patient portals
– Telehealth
– Remote p...
Thomas Graf, MD
www.PopulationHealthNews.com
• CMO Population Health and Longitudinal
Care Service Lines, Geisinger Hea...
Camden Coalition
• Jeffrey Brenner, MD Hotspotting
• Data from hospitals
• Triage
• High risk (care management)
• Int...
Camden Coalition
• Goals of program
• Reduce readmissions and costs for complex
patients
• No open referrals
• No dup...
Camden Coalition
• Intermediate risk outreach team
– RN
– LPN
– Health coaches
• High risk outreach team
– RN
– MA ...
Camden Coalition High Risk
• Hospital utilization
• 2 or more chronic conditions
• Low socioeconomic status
• Homeless...
Camden Coalition
• The Transitional Care Model: Mary D.
Naylor, PhD, University of Pennsylvania
School of Nursing
• Th...
Food Service & Environmental
Protection Worker Job Program
• Disease prevention and job training viewed
as two separate...
Kent Bottles, MD
Consulting Principal, PYA
CMO, PYA Analytics
Lecturer, Jefferson University School
of Population Heal...
of 49

Population Health

PYA Principal Kent Bottles, MD, who is also Chief Medical Officer of PYA Analytics, presented before healthcare information technology (IT) professionals at the Summit of the Southeast—Driving the Future of Technology held at Nashville Music City Center, September 16-17, 2014. Dr. Bottles’ presentation covered population health.
Published on: Mar 4, 2016
Published in: Healthcare      
Source: www.slideshare.net


Transcripts - Population Health

  • 1. Population Health Kent Bottles, MD kbottles#@pyapc.com Summit of the Southeast 2014 Driving the Future of Healthcare Technology September 16-17, 2014 TN HIMSS
  • 2. Population Health Definitions • “The health outcomes of a group of individuals, including the distribution of such outcomes within the group and the policies and interventions that link outcomes and patterns of health determinants” • David Kindig & Greg Stoddart
  • 3. Population Health Definitions • “A conceptual framework for why some populations are healthier than others as well as the policy developments, research agenda, and resource allocation that flow from this framework.” • T. K. Young
  • 4. Population Health Statistics • The county of residence in USA means a 14-year difference in life expectancy • On the Blue Washington DC subway route, there is a 9-year difference in life expectancy between downtown and Fairfax, Virginia • Rheumatoid arthritis & DM associated with living close to highly traveled roads
  • 5. Population Health Statistics • Your zip code is more important than your genetic code for health and wellness • College grads live 5 years longer than those without a high school diploma • Detroit with 139-square-mile area and 900,000 people has only 5 grocery stores
  • 6. Population Health Statistics • British Medical Journal- higher levels of greenery and lower graffiti correlated with increased exercise & decreased obesity • Cities with sidewalks have fitter individuals than suburbs without sidewalks
  • 7. Social-Ecological Model Individuals Social, Family, and Community Networks Living and Working Conditions Broad Conditions and Policies
  • 8. Population Health & Hospital • Hospital-centric care model is changing to population health management care model based on care coordination across fragmented continuum of care • We used to only interact with patients when they presented to office or hospital • Now we must interact with patients who do not show up for care
  • 9. Population Health & Hospital • Sharing data across all points of care is only way to provide coordinated care • Data access becomes critical for patients, families, doctors, staff • Mobile applications become more important and essential
  • 10. Population Health Strategies • Fitness and exercise promotion • Obesity management and weight reduction • Diet and nutrition • Stress management • Reductions in smoking and substance abuse • Protected sex and family planning • Physical activity and moderate amounts of exercise • Auto safety; drunk driving • Chronic disease management • Food safety • Clean water, sewers • Promoting healthy communities • Economic incentives for healthy behaviors • Universal coverage to encourage preventive care
  • 11. Community- Major Site of Health Care Green, et al., (2001) NEJM, 344:2021-25 • 1,000 adults living 1 month • 800 report symptoms • 327 consider seeking care • 217 seek care (physician) (113 primary care) • 65 visit complementary/alternative provider • 21 visit hospital outpatient clinic • 14 receive home care • 8 hospitalized (1 in AHC)
  • 12. We Can Do Better Steven A. Schroeder, MD, NEJM, September 20, 2007 Health is influenced by •Genetics •Social circumstances •Environmental exposures •Behavior •Health care
  • 13. We Can Do Better Steven A. Schroeder, MD, NEJM, September 20, 2007 • The single greatest opportunity to improve health and reduce premature deaths in America lies in personal behavior • Behavior causes 40% of all deaths in USA
  • 14. Proportional Contribution to Premature Death Environmental Exposure 5% Health Care 10% Social Circumstances 15% Genetic Predisposition 30% Behavioral Pattern 40% Determinants of Health and Their Contribution to Premature Death.
  • 15. Root Cause Analysis – Key Drivers of Health Driver Definition % Contribution Behavioral Choices Diet, physical activity, sex, substance abuse, stress. (Source: “The Case for More Active Policy Attention to Health Promotion”; McGinnis, Williams Russo; Knickman); Health Affairs, Vol. 21, No. 2, March/April 2002) 40% Genetics Genetic make-up that creates a pre-disposition to certain illnesses. 30% Social Circumstances Education, employment, income, poverty, housing, crime exposure, social cohesion. 15% Medical Care Access to and quality of medical treatment. 10% Environmental Conditions Exposure to toxic substances, pollutants, accidents and infectious diseases. 5% TOTAL 100%
  • 16. North Karelia in Finland • Focus on nutrition, tobacco use, exercise • Decreased heart attack deaths by 70% • Decreased lung cancer deaths by 70% • Male life expectancy increased 65-73 yrs. • Mayo Clinic CardioVision 2020 WSJ, January 14, 2003
  • 17. North Karelia in Finland • “Stubborn persuasion.” No power. • “What we’ve done better than the US is we’ve managed to get the whole community involved.” • Dr. Pekka Puska leafleted markets • Dr. Pekka Puska on local TV • Yellow cards to record BP
  • 18. North Karelia in Finland • Alter local diet (from dairy and sausage to greens “food for animals”). • Per capita vegetable consumption per year from 44 pounds to 110 pounds. • Per capita berry consumption tripled to 143 pounds per year. • Dairy industry negative ads in newspaper. • Half number of cows compared to 1970.
  • 19. Stress, Loneliness, and Death • High Stress = 57% • High Isolation = 31% • Both High: 20% of Sample – 3-fold increased risk • One High: 48% of Sample – 2-times risk • None High: 32% of Sample All significant at p<0.001 Variable Relative Risk of Death Relative Risk of Sudden Death Psychosocial Variables 4.6 5.6 Ventricular Arrhythmia 3.8 5.7 Myocardial Dysfunction 3.1 3.7 Age 2.0 - Cigarette Smoking 2.1 1.6
  • 20. Emotional Support and Mortality The EPESE Cohort Patients who reported no emotional support had almost three times the risk of death (odds ratio 2.9; 95% Cl, 1.2 – 6.9):
  • 21. BMJ: 2005; 331: 611-612 • Higher levels of greenery, lower levels of graffiti and litter correlated with: – Higher levels of physical activity (3x) – Lower levels of obesity (40% less)
  • 22. Whiplash Pain and Culture • Lithuania: no car insurance, no intractable neck pain and lingering headaches • Norway: car insurance, 70,000 person organization for neck pain, headaches • Cultural forces at work in reinforcing pain & dysfunction include insurance, self-help groups, class-action lawsuits, powerful patient organizations
  • 23. Social Networks & Medicine Gina Kolata, NY Times, August 5, 2007, WK 1 • NEJM study of social network of 12,067 people followed for 32 years • Obesity can spread from friend to friend like a virus • Networks amplify whatever effect they are propagating • Smoking, depression, suicide
  • 24. Why is it so hard to activate a community to be healthy? • Health poorly defined. • Communities in disarray. • Biomedical model does not provide language sufficient to address culture. • Biocultural model & language may be required. • Health promotion: complex not complicated. • Getting started in uncertain environment. • Leadership: no one’s day job, nonprofit politics. • But, we must begin…
  • 25. Population Health Requires Providers to Deal with Strangers • Schools • Police • Urban Planners • Economic development agencies • Job corps • Transportation • Many others
  • 26. Non-provider health influencers • Religious entities promoting health behavior • Transportation facilitates access • Housing authority influences environment • Gyms • Restaurants • Malls
  • 27. Non-medical influencers • Lifestyle determinants of wellness status • Socioeconomic determinants • Subpopulations (kids, frail, comorbidities) • Partner with non-provider organizations • Identify specific patient interventions • Dialogue with non-providers organizations • Establish outcome metrics to measure
  • 28. Dennis Weaver, MD/Adirondack Health Institute Pilot • Percentage of patients with BMI>95% went from 16% to 14% • Percentage of patients who returned to normal BMI went from 4% to 14%
  • 29. Mature PHM • Organized system of care • Care teams • Coordination across care settings • Access to PCP • Patient self management • Linked EHRs and patient registries • Focus on behavior and lifestyle changes
  • 30. Mature PHM • PCMH and the medical neighborhood – Prevention – Shift from acute to chronic care – Predictive and proactive – Continuous, not episodic – Whole person oriented, not case oriented – Care for people when they do not present to office or hospital
  • 31. Medical Neighborhood • PCP • Specialists • Hospitals • Rehab and long term care • Home health agencies • Pharmacies • Labs and imaging centers
  • 32. Patient engagement • Judith Hibbard’s Patient Activation Measure 4 level scale • Self-management • Collaboration with provider • Maintaining function/preventing declines • Access to appropriate care
  • 33. Patient engagement • Jessie Gruman’s Center for Advancing Health- 43 engagement behaviors organized in 10 categories
  • 34. Patient engagement 10 Categories • Find safe care • Talk to providers • Organize health care • Pay for health care • Make decisions • Participate in care • Promote health • Get preventive care • Plan end of life • Seek knowledge
  • 35. Jessie Gruman on Patients • As a savvy and confident patient who is flummoxed by so much of what takes place in health care, I am regularly surprised by how little you know about how little we patients know…
  • 36. Jessie Gruman on Patients • You are immersed in the health culture. But we don’t live in your world. So we have no idea what you are talking about much of the time. One way to help us feel competent in such unfamiliar environments is to give us some guidance about what this place is and how it works. What are the rules?
  • 37. Role of HIT in PHM • Identify and track cohorts of patients – By risk level – By adherence to care plans – By medication use – By achievement of therapeutic targets
  • 38. Role of HIT in PHM • Profiling the population • Point of Care • Patient engagement and managment
  • 39. Role of HIT in PHM • Profiling the population – Patient registries – Advanced population predictive analytics – Risk stratification
  • 40. Role of HIT in PHM • Point of care – EHR – Health information exchange – Referral tracking
  • 41. Role of HIT in PHM • Patient activation and management – Automated outreach – Patient portals – Telehealth – Remote patient monitoring
  • 42. Thomas Graf, MD www.PopulationHealthNews.com • CMO Population Health and Longitudinal Care Service Lines, Geisinger Health • 350% increase in patients receiving all recommended screening tests • ProvenCare model for 350,000 patients with 7% reduction in cost for Medicare aged patients
  • 43. Camden Coalition • Jeffrey Brenner, MD Hotspotting • Data from hospitals • Triage • High risk (care management) • Intermediate risk (care transitions)
  • 44. Camden Coalition • Goals of program • Reduce readmissions and costs for complex patients • No open referrals • No duplicate services • Facilitate clinical coordination
  • 45. Camden Coalition • Intermediate risk outreach team – RN – LPN – Health coaches • High risk outreach team – RN – MA – Health coaches – Social worker
  • 46. Camden Coalition High Risk • Hospital utilization • 2 or more chronic conditions • Low socioeconomic status • Homeless or unstable housing • Lack of social support, HS diploma • Behavioral health issues • Generational poverty/urban violence
  • 47. Camden Coalition • The Transitional Care Model: Mary D. Naylor, PhD, University of Pennsylvania School of Nursing • The Care Transitions Program: Eric Coleman, MD, Division of Health Care Policy and Research at the University of Colorado School of Medicine
  • 48. Food Service & Environmental Protection Worker Job Program • Disease prevention and job training viewed as two separate strategies for development • Alignment of strategies creates jobs that can improve health • New Jersey school heat-and-serve french fries had 5x expected fat content due to improper drainage or treatment of oil • Health Affairs, November 2011
  • 49. Kent Bottles, MD Consulting Principal, PYA CMO, PYA Analytics Lecturer, Jefferson University School of Population Health

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