Population Health

Question 1

What is population health?

Answer 1

Population health refers to the health outcomes of a defined group of people, where the population is defined by the stakeholder (e.g., clinic panel, health system, employer, insurance group).

Question 2

How does population health differ from public health?

Answer 2

Public health focuses on society-wide policies and programs to improve health conditions broadly (e.g., infectious disease control, environmental protection), while population health focuses on improving outcomes for a specific defined group (e.g., people over the age of 65, people with arthritis).

Question 3

What are the components of the Triple Aim?

Answer 3

(1) Improve patient experience of care, (2) improve population health, and (3) reduce per-capita healthcare costs.

Question 4

How did the Triple Aim expand over time?

Answer 4

It expanded to the Quadruple Aim by adding care team well-being, and then to the Quintuple Aim by adding the advancement of health equity.

Question 5

What 4 factors does population health focus on to try and improve health outcomes?

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Answer 5

Preventive care (as opposed to sick care), coordination of care among physicians and systems, utilization of data to drive change, and bidirectional communication with patients.

Question 6

What is a Patient-Centered Medical Home (PCMH)?

Answer 6

Team-based primary care model focused on coordinated, patient-centered care that integrates physicians, nurses, social workers, and other providers; places an emphasis on engaging patients in their care.

Question 7

What is the key difference between an ACO and a PCMH?
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Answer 7

ACOs operate at the system level with high financial risk and a focus on reducing waste, while PCMHs operate at the clinic level with **low financial risk **and a focus on care coordination and patient experience.

Question 8

What tools are commonly used to improve population health?
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Answer 8

EHR-based dashboards (to reach out to patients for intervention), patient portals (for bidirectional communication with patients), and wearable technology (to remotely track population health)

Question 9

How are MACRA and MIPS used to improve population health?
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Answer 9

Incentivise value over volume by tying medicare payments to certain metrics, including quality and cost of care, efforts to improve care, and interoperativity (i.e., use of EMR systems)

Question 10

What is Readmission Reduction?

Answer 10

When an ACO/ PCMH works with the patient following hospitalization to ensure timely continuation of care that prevents re-hospitalization

Includes scheduling of follow up appointments and obtaining prior authorization for necessary medications