Deliverable 6 - Chronic Diseases and Population Health Management
soniam
02.2026HSA5300PopulationHealthModuleSixChronicDiseasesandPopulationHealthManagement11.pptxModule 6 Chronic Diseases and Population Health Management
Dr. M. Point
HSA5300CBE
Population Health
Motivational Quote for this Week
Presentation Goals
Examine Key Elements in Successful PHM/DM
01
Explore risk factors affecting PHM/DM
02
Review deliverable requirements
03
REMINDER OF COURSE DEADLINE
04
Episodic Care
Traditional healthcare systems focus on episodic care—patients come in when they’re sick.
Episodic care happens when:
A patient seeks care for a single illness, injury, or symptom
Care ends once the immediate issue is treated
There is little or no follow-up beyond that episode
Population Health
Population Health Management (PHM) is a systematic approach to improving the health outcomes of a defined group of people by:
Using data to identify health risks
Coordinating care across providers and settings
Addressing social, behavioral, and environmental factors
Measuring outcomes and continuously improving interventions
The Shift
Why this shift is happening:
Rising chronic disease rates
High healthcare costs
Health disparities across communities
Movement toward value-based payment models
The Benefits of PHM
Benefits of PHM:
Improved health outcomes
Reduced emergency department visits and hospitalizations
Lower costs over time
Better patient experience
Greater health equity
Disease Management
Disease management focuses on people who already have a specific condition, such as:
Diabetes
Asthma
Hypertension
Heart failure
Population Health Versus Disease Management
Population health asks:
Why is this population getting sick, and what systems need to change to improve outcomes?
It looks upstream, often before disease worsens—or even before it starts.
Disease management asks:
How do we help people with this condition manage it better and avoid complications?
It is typically:
Condition-specific
Clinically focused
Ongoing and structured
Welcome to Module Six
For this competency, you will develop a population health plan to address a health concern in the current healthcare industry.
Scenario
The key to an effective and sustainable population health management program is to know your chronic disease patients and coach them.
Scenario
The success of population health and chronic disease management efforts hinges on a few key elements:
identifying those at risk,
having access to the right data about them,
creating actionable insights about patients, and
coaching them daily toward healthier choices.
Common Chronic Diseases
Diabetes
Hypertension
Depression
Breaking It Down
Know your chronic disease patients and coach them.
Define Target Population
Develop Criteria
Educate, Inform, Critique, Evaluate
Key Elements in Successful PHM/DM
Identifying those at risk, having access to the right data about them, creating actionable insights about patients, and coaching them daily toward healthier choices
PHM – shifts from process-based care to patient-oriented outcomes
DM – based on the chronic care model and aims to improve quality in care delivery
Disease Management
Disease management grew from attention to the truism that 20 percent of the patients in a given population will account for 80 percent of the costs.
The Focus of DM
Disease management focuses on chronic conditions, most commonly those affecting large numbers of beneficiaries, such as diabetes or congestive heart failure (CHF).
Key Term
Risk Stratification – a systematic process by which patient risk levels are identified and predicted.
A "one-size-fits-all" model, where the same level of resources is offered to every patient, is clinically ineffective and prohibitively expensive (Pilar, 2017).
The goal is to identify highest risk patients which enables for the prioritization of interventions, therefore, improving patient outcomes.
Risk Stratification
To group patients according similarity and complexity of care needs.
Categories for Risk Stratification
Highly complex. This is a small group of patients with the greatest care needs. This group, likely less than 5% of the population, has multiple complex illnesses, often including psychosocial concerns or barriers.
High-risk. The next tier includes patients with multiple risk factors that, if left unmanaged, would result in them transitioning into the highly complex group. It typically describes about 20% of the patient population.
Categories for Risk Stratification
Rising-risk. This tier includes patients who often have one or several chronic conditions or risk factors, and who move in and out of stability with their conditions
Low-risk. This group includes patients who are stable or healthy. These patients have minor conditions that can be easily managed. The care model for this group aims to keep them healthy and engaged in the health care system, without the use of unnecessary services.
Identifying Risk
Highly complex
High-risk
Rising-risk
Low-risk
Identifying those At-Risk
At-Risk populations are the individuals who are considered most vulnerable with respect to disparities in access, service use, and outcomes.
May be defined by race, ethnicity, gender, primary language, etc.
Health Disparities
Identifying those At-Risk
These individuals are typically those with some combination of tough chronic diseases, complicated behavioral health issues, and adverse social conditions.
These individuals are more likely to create a strain on the health system, requiring treatment from various providers and significant investment of resources – time and money.
Instructions
As your health system is drafting a strategic framework for the PHM program, you are tasked with creating a PowerPoint presentation with detailed speaker notes in each content discussion slide. Explain the relationship between disease management and population health needed in the following areas:
Describe the prevalent chronic diseases for the population your health system is serving.
Prevalence equals the commonality of the disease. How common is the disorder?
Example: Obesity, High Blood Pressure, Diabetes, etc.
Instructions
Describe the risks associated with the proliferation of these chronic diseases.
What is the associated risk?
For example, what is the risk factor for developing obesity?
Sedentary Lifestyle, Dietary Choices, Metabolic conditions, etc.
Stroke
HBP
Sedentary Lifestyles
Instructions
Assess how the population will access information and resources to prevent and manage chronic diseases.
What is your plan to communicate prevention?
How will you address the management of chronic disease among your targeted population?
Remember, you are developing a PHM program which started with Module One’s deliverable
Instructions
Construct a chronic disease communication plan that helps patients with chronic diseases to pursue healthier choices and to use population health resources.
Example of a Plan
Ex. Communications Plan
Instructions (Part II)
Use your findings from prior summative assessments in modules 01, 02, 03, 04, and 05 to create the PowerPoint. Use five quality references to support your assessment and findings.
Your presentation should discuss the data that you collected in the previous modules.
For instance, if I presented data in a previous week that shows SC ranked at #5 in obesity, that should be included in my presentation.
How Will I Be Assessed?
Review the rubric
Review each criteria carefully
Submit, Submit, Submit
Supportive Reminder
Please keep in mind the final day to submit is Friday, March 20th
Please have a plan!
What Happens Going Forward?
We will hit the reset button following the Module 7’s deliverable presentation…
Questions
