Dr_Candice

AM J HEALTH-SYST PHARM | VOLUME 74 | NUMBER 18 | SEPTEMBER 15, 2017 1405

CONCEPTS AND DEFINITIONS SPECIAL FEATURES

Population health management: Review of concepts and definitions

Meghan Swarthout, Pharm.D., M.B.A., Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD, and Johns Hopkins Outpatient Pharmacy, Baltimore, MD.

Martin A. Bishop, Pharm.D., M.S., Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD.

This article is part of a special AJHP theme issue on population health management. Contributions to this issue were coordinated by AJHP Editorial Advisory Board member Kenneth M. Shermock, Pharm.D., Ph.D.

Address correspondence to Dr. Swarthout ([email protected]).

@MeghanDavlin

This article is part of a special AJHP theme issue on population health management. Contributions to this issue were coordinated by AJHP Editorial Advisory Board member Kenneth M. Shermock, Pharm.D., Ph.D.

Copyright © 2017, American Society of Health-System Pharmacists, Inc. All rights reserved. 1079-2082/17/0902-1405.

DOI 10.2146/ajhp170025

Purpose. The terms population health, population health improvement, and population health management are discussed.

Summary. A key concept in defining population health activities is clearly delineating the population(s) of focus. The Institute for Healthcare Improve- ment’s (IHI’s) Triple Aim Initiative uses the term population health manage- ment to describe the work by healthcare organizations to improve out- comes for individual patients to maximize population health. The National Academy of Medicine favors the term population health improvement and uses this term to describe work to identify and improve aspects of or contributors to population health, expanding the focus beyond traditional healthcare delivery systems. As organizations like IHI and the National Academy of Medicine continue to focus on population health, the terms and definitions used to describe these activities will continue to evolve.

Conclusion. The use of consistent, clear definitions for population health activities is critical to the practice of pharmacy and healthcare delivery.

Keywords: delivery of healthcare, patient care management, pharmacy, population groups, population health, public health

Am J Health-Syst Pharm. 2017; 74:1405-11

Population health has been identi-fied with increasing frequency as a key element in patient-centered, accountable healthcare delivery. The exact origin of the term population health is unknown.1 Szreter1 noted that work by Morris and Titmuss2-4 during World War II created the origi- native models for modern popula- tion health study. Morris and Titmuss outlined that social conditions, such as unemployment, appeared to be linked to variations in prevalence for conditions such as peptic ulcer dis- ease and rheumatic heart disease. Fast forward 73 years, population health is becoming one of the most popu- lar and frequently studied concepts in the ongoing pursuit of optimizing the healthcare system in the United States.

Indeed, improving the health of populations is 1 of the 3 key compo- nents of the Institute for Healthcare

Improvement’s (IHI’s) Triple Aim.5 First outlined in 2008, the Triple Aim framework is an approach to improv- ing health-system performance by si- multaneously focusing on improving the individual patient experience, im- proving health outcomes for popula- tions of patients, and reducing the per capita cost of healthcare. Achieving the goals of the Triple Aim has become a fundamental element of the mission of many health systems in the United States, and understanding how to im- prove population health is critical to achieving this mission.

The goal of this article is to lay the foundation for other articles in this issue by outlining the different terms and definitions used to describe population health activities. We will share a summary of proposed defini- tions, review prevailing definitions, and provide examples of how phar- macy practice models align with the

SPECIAL FEATURES

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definitions for the terms population health, population health improve- ment, population health management, and population health equity. Often these terms are used interchangeably, creating further confusion. Our goal is to provide a primer for key population health terminology and outline why the definitions are important. Table 1 lists the most common terms used and provides some of their published defi- nitions. Figure 1 shows a conceptual model of how the terms are related.

Public health

The American Public Health Asso- ciation (APHA) defines public health as the promotion and protection of the health of people and the com- munities where they live, learn, work, and play.6 The definition notes that public health is focused on disease prevention, wellness, and healthy behaviors. In 2006, APHA developed a policy statement on the role of the pharmacist in public health.7 The statement denotes that pharmacists can positively influence public health as highly accessible healthcare pro- fessionals, and APHA encourages pharmacist training in public health concepts. The position outlines a number of activities performed by pharmacists that can improve public health, including health screenings, immunizations, pain control, smok- ing cessation, drug abuse prevention, clinical pharmacotherapy research, family planning, and the promotion of self-care management.7

Many studies have demonstrated that pharmacists’ efforts support achievement of public health goals. For example, pharmacist-provided immunizations increase access to care and have resulted in an increase in the number of immunized patients.8 Increased immunization rates is a key goal for the Healthy People 2020 ini- tiative.9 In addition, published models have outlined the role and importance of pharmacists in emergency pre- paredness and public health disaster response.10,11 Pharmacists also provide an important function in the public

KEY POINTS • Population health manage-

ment is one of the components of the Institute for Healthcare Improvement’s Triple Aim and has been used to describe the service infrastructure designed to improve population health outcomes.

• Population health improvement has been used by the National Academies of Sciences and describes collaborative action by diverse stakeholders to opti- mize health by improving broad determinants of health.

• Pharmacists are developing new models of care that extend beyond traditional healthcare delivery models to improve the health of populations.

health activity of health policy advo- cacy, as demonstrated through state and national efforts to expand phar- macists’ scope of practice and achieve provider status to increase patient ac- cess to pharmacist-provided care.12

Population health

A standardized definition for pop- ulation health from a professional as- sociation does not currently exist. In the American Journal of Public Health in 2003, Kindig and Stoddart13 out- lined a definition of population health that is commonly used in literature and practice. Reviewing a number of definitions from scholarly works and health policy organizations, they ulti- mately included both the health out- comes and the distribution of those outcomes within the group in the def- inition of population health. Impor- tantly, Kindig and Stoddart noted the need to use population health mea- sures that are dependent on a broad range of health determinants, such as Years of Health Life used in Healthy

People,14 to accurately assess popula- tion health outcomes.

A key concept of population health is understanding how populations are defined. Some population health lead- ers may consider geographic areas, such as a county or select ZIP codes.15 Other population health stakeholders, like payers or health systems, may de- fine a population based on the group of patients seeking care from a select group of primary care providers or a group of patients covered under a spe- cific health plan. Still other population health initiatives focus on patients with similar diseases.

Understanding and defining popu- lations are important for ensuring clar- ity. Populations can be defined by a va- riety of characteristics, such as patient age, payer group, primary care pro- vider attribution, geographic region, or disease. Diez Roux16 cautioned that the narrowing of population health to groups of patients with specific condi- tions or providers may be missing the bigger picture of population health. She urged less focus on outlining what distinguishes population health from public health and noted that improving population health can only be achieved through a holistic focus on social deter- minants, biological determinants, and elements of health equity.

Sharfstein17 also discussed the widespread, often confusing, and col- loquial use of the term population health in modern healthcare discus- sions. He provided lists of services that organizations are including under the umbrella term population health, and these lists include the terms phar- macy, pharmacy benefit management, and pharmaceuticals. Interestingly, pharmacists are not explicitly men- tioned in the lists. Sharfstein chal- lenged those working in population health to “define success or failure by not only those served but also those left behind.” For example, if popula- tion health efforts are focused on pa- tients covered by a specific insurance type, uninsured patients may be un- intentionally excluded from receiving services.

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Table 1. Definitions of Population Health Terminology

Term Definitions

Population health • The health outcomes of a group of individuals, including the distribution of such outcomes within the group.13

• A holistic focus that requires the consideration of a broader array of the determinants of health than is typical in either health care or public health and recognizes shared responsibility for population health outcomes with diffuse accountability.15

• A conceptual approach to understanding the drivers of health and consequently the strategies most useful to improve health; includes both the need to consider factors in social and biologic processes impacting health and an explicit concern with health equity.16

• Encompassing the impact of income inequality, educational differences, and unjust disparities beyond the traditional healthcare delivery system and “biomedical paradigm” with focus on the underlying cause of illness.17

Population health improvement

• The enhancement of the health of all individuals in a population, with greater emphasis on factors and influences unrelated to health care.25

• Collaborative action by a community of science-informed leaders in public health, health care, business, education and early childhood development, housing, agriculture, transportation, economic development and community- and faith-based organizations. Recognizes that outcomes are shaped by interdependent social, economic, environmental, genetic, behavioral, and health care factors, and will require robust national and community-based policies and dependable resources to achieve improvement.20

Population health management

• Programs targeted to a defined population that use a variety of individual, organizational, and societal interventions to improve health outcomes.22

• A variety of interventions tailored to patients based on their levels of risk, with the patients’ risk level determining what interventions they are offered . . . concerned with the total population of patients, from those with minimal health risks to those who have complex health conditions. . . . with the goal of slowing the progression of risk in the patient population and at the same time to minimize the use of costly utilization, such as emergency department.23

• A patient-centered, integrated care delivery model based on aligned incentives and coordinated, collaborative processes that are built on evidence-based prevention and disease management protocols.24

• The use of a global budget to manage the health of a specific population, generally those who seek care or may eventually seek care at a health system or institution.25

Figure 1. Conceptual framework for population health definitions.

Public health

Population health

Population health

improvement

Population health

management

Population health equity

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Population health encapsulates both health outcomes and determi- nants of health. There are published examples of service models that aim to improve determinants of health and optimize health outcomes. Due to ambiguity between the terms popu- lation health and population health management, it can be difficult to discern if the published models are examples of population health or population health management. The Community Aging in Place, Advanc- ing Better Living for Elders trial is such an example.18 The study goals were to decrease hospitalizations and nursing home use in older adults by improving the health and quality of life for pa- tients in their own home. The model involved pharmacists providing con- sultative services for patients on high- alert medications and for patients taking more than 15 medications. The trial involved a nurse, an occupational therapist, and a handyman. The ap- proach of including a nontraditional team member, such as a handyman, to address the patient’s home environ- ment conditions to improve activities of daily living is an example of some of the community-based partnerships the definitions of population health discuss. Studies have also demon- strated that pharmacists can play an important role in optimizing health behaviors and addressing underlying determinants of disease in popula- tions. A longitudinal study conducted in a Veterans Health Administration clinic demonstrated that pharmacists can have a lasting effect on helping patients become tobacco free and live a healthier lifestyle.19

Population health management versus improvement

Understanding that the majority of proposed definitions of population health are conceptual frameworks, the terms population health manage- ment and population health improve- ment have been used to describe ac- tionable population health activities. These terms are often used to outline pragmatic approaches to improve

outcomes and optimize the health of populations and are sometimes used interchangeably. As noted previously, a primary goal of the IHI’s Triple Aim Initiative is to improve the health of populations.5 Once a population is identified and desired outcomes are defined, it is incumbent on healthcare organizations to work toward improv- ing these outcomes for individual pa- tients to maximize population health using population health management infrastructure and population health improvement techniques.

The National Academy of Medi- cine favors the term population health improvement.20 The National Academy of Medicine has an orga- nized roundtable on the topic of population health improvement and conducts workshops with the goals of identifying and improving contribu- tors to population health, specifically including education. The suggestion that population health can always be improved is similarly evoked in the IHI’s Triple Aim implementation tools.21

Many other organizations and ar- ticles use the term management as analogous to the word improvement, where population health manage- ment activities are intended to main- tain and improve health.22-25 The term population health management was directly referenced in an article re- garding the Triple Aim. In that article, Berwick et al.5 used this term to de- scribe how an integrator—or an or- ganization that accepts responsibility for all 3 aims of the Triple Aim—would deploy its resources to address areas of need within its segmented population. Berwick and colleagues proposed that organizations seeking to achieve the Triple Aim must develop population health management strategies, in- cluding preventive services, care mod- els that detect and intercede when early signs of health deterioration are identified, and community-based programs that address determinants of mental health problems. Based on this definition, the term population health management should be used to

describe the infrastructure devoted to delivering interventions.

Washington and colleagues25 pos- tulated that population health im- provement is the “third curve” in the transformation of academic health systems, with the first curve being in- dividual patient care and the second curve being population health man- agement. They described population health management as using a capi- tated budget to manage the health of a specific population that generally seeks care at a specific institution. They explained that the third curve of popu- lation health improvement extends further to reach patients who do not seek healthcare through traditional de- livery models and includes greater em- phasis on factors traditionally unrelat- ed to healthcare, including education, employment, and the physical envi- ronment. The incentives for health sys- tems to engage in these efforts include ensuring a healthy future workforce, having a deeper understanding of how health systems can influence broader health determinants, and facilitating compliance with growing regulations to focus on community needs. Steps that health systems can take to move toward population health improve- ment are provided, including making population health improvement part of the organization’s mission, forging new partnerships with other commu- nity sectors, creating healthy campus- es, and leveraging other professional schools that may be affiliated with aca- demic institutions.25

There are numerous published ex- amples of pharmacist-led population health management activities that span across diverse populations and care settings26-33; examples are pro- vided in Table 2. Interventions may be provided to patients in the communi- ty setting through employer wellness programs or as extensions of primary care provider visits.26-30 Other exam- ples align with Washington et al.’s25 definition for the second curve of pop- ulation health management, focusing on reducing preventable readmis- sions for patients who were recently

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hospitalized.31-33 Some examples use pharmacists to promote healthy life- style behaviors and preventive well- ness activities.26,28 In other examples, pharmacists actively manage medica- tion regimens through collaborative

practice models.27,29 Some models use a team-based approach that include pharmacists’ involvement.28,31,32 Popu- lation health management as a do- main under population health focuses on the identification of an at-risk pop-

ulation, the development of a strategy to improve specific health outcomes of the defined population, and the implementation of a pilot program to assess the feasibility and impact of the proposed strategy.

Table 2. Examples of Population Health Managementa

Ref. Topic Interventions Results

26 Employee health assessment and targeted improvement activities

Health risk assessment followed by participation in health improvement activities (lifestyle management, health issue triage, and disease management) supported by financial incentives

Instituting these changes led to a reduction of health risks such as obesity, high blood pressure, and depression.

27 Community-based pharmaceutical care services for Asheville city employees with diabetes

Education by certified diabetes educators, long-term community pharmacist follow- up with clinical assessment, treatment goal setting, and collaborative drug therapy management with physicians

Mean HbA 1c

value decreased at all follow- ups, with risky patients with worse disease control deriving additional benefits. Costs shifted from inpatient and outpatient physician services to prescriptions. Total mean direct medical costs decreased by $1,200–$1,872 per patient per year compared with baseline. Days of sick time decreased every year (1997–2001) for 1 employer group, with increases in productivity estimated at $18,000 annually.

28 Community-based, pharmaceutical care appointments for patients in self-insured health plans

Education by personal health coach, pharmacist, nurse, or dietitian for diabetes, hypertension, or dyslipidemia or an extension of the Asheville Project with enhanced EHR access

Total costs for participants decreased, especially for patients with diabetes. Clinical outcomes of all 3 diseases significantly improved.

29 Community-based pharmaceutical care services for employees at 10 locations

Diabetes self-management care services provided by pharmacists in the community via scheduled visits within a collaborative care management model

Total costs for participants decreased. Clinical outcomes significantly improved for HbA

1c value, systolic blood pressure,

and low-density lipoprotein level. Other wellness interventions (e.g., vaccinations, eye and foot exams) were more common.

30 Medication management services by pharmacists for Medicaid recipients in Connecticut

General medication management visits with pharmacists between primary care physician visits, focusing on patients with at least 1 chronic condition and at least 3 prescriptions

Pharmacists identified a wide variety of medication issues, such as discrepancies unreconciled, omitted medications for problems, and unnecessary medications. Costs from medication claims and medical claims were reduced.

31, 32 Reduction of hospitalizations and emergency room visits through optimized discharge and postdischarge management

Nurse discharge advocate worked with inpatients to arrange follow-up appointments, confirm medication reconciliation, and conduct patient education; clinical pharmacist called patients 2–4 days after discharge to reinforce the discharge plan and review medications.

A pharmacist telephone intervention as part of a comprehensive discharge protocol had a positive impact on patients during the transition-of-care process by reducing the rate of unplanned hospital use.

33 Prevention of adverse drug events after hospitalization through pharmacist transition-of- care services

Pharmacist provided education at discharge and during a follow- up telephone call 3–5 days later; interventions focused on clarifying medication regimens, monitoring for adverse events, providing adherence support, and counseling patients.

Preventable adverse drug events were detected at a significantly higher frequency in the intervention group. No difference in healthcare utilization was found.

aHbA 1c

= glycosylated hemoglobin, EHR = electronic health record.

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Summary and future directions

As population health continues to be an area of focus for the achieve- ment of the Triple Aim, there is no doubt that population health terms and definitions will continue to evolve. For example, there is an emerging use of the term population health equity to ensure the inclusion of health- care disparity–improvement efforts through population health interven- tions. As discussed previously, many nonclinical determinants of health are essential to the population health framework. Disparities in healthcare delivery are widely documented, and these disparities are the motivation of public health initiatives in cardio- vascular disease and other significant clinical issues.34,35 Health systems em- barking on population health activi- ties should structure their resources and interventions with a focus on eq- uity in population health, which will support work in public health and health policy. Engaging patients and communities to promote and support population health improvement—or the democratization of healthcare— with improved access to care, shared decision-making, and health informa- tion technology, will create a synergy with the efforts of health systems in achieving the Triple Aim.36

The use of consistent, clear defini- tions has always been critical to the practice of pharmacy and healthcare delivery. The importance of main- taining clarity of terms remains true, as health systems are challenged to look beyond the traditional care de- livery model to improve the health of broader populations. Pharmacists should use the published defini- tions and frameworks for population health terminology as a guide to de- velop innovative practice models that extend beyond traditional healthcare settings and delivery processes to engage diverse community stake- holders. Pharmacists are well posi- tioned across the continuum of care in health systems to be indispensable stakeholders in population health im- provement efforts.

Conclusion

The use of consistent, clear defini- tions for population health activities is critical to the practice of pharmacy and healthcare delivery.

Disclosures The authors have declared no potential conflicts of interest.

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