Deliverable 5 - Population Health Management Patterns

Live Class Module 5 Recording - HSA5300

February 3, 2026, 11:21PM

27m 59s

Merle Point-Johnson started transcription

Merle Point-Johnson 0:03 Deliverable in the Population Health Management course. So we're going to go ahead and get started. I'd like to start by offering a motivational quote. It is absolutely one of my favorites. So if you're in many classes with me, there's probably a significant likelihood that you've seen this. Quote before. I love this quote because it makes so much sense to me. This the and the take away from it. Hopefully everyone gets this take away. So the quote goes a bird sitting on a tree is never afraid of the branch breaking because his trust is not in that branch. But in its own wings, always, always, always bet on you. Always believe in yourself. You might have to be your only cheerleader. You certainly need to be your loudest. Yes, family, friends, and that support system that you have in place. That is definitely going to be beneficial to you, but because especially on those days when you can't cheer for yourself, that that support system comes in loud for you. But on those days where you need to stand up and, you know, take responsibility, take action for yourself, that's what it's all about. To believe that those actions that you're taking are going to be the actions that you need. So always believe in yourself. The take away is to trust yourself, OK? All right. So I also want to remind everyone of the very important upcoming end of course and March 20th, Friday, March 20th is a final day that you'll be able to submit any coursework for this particular term and you will. Find that the drop boxes are locked at that point, so please plan in advance. Please take into consideration the need for you to really be prepared to submit your work in advance of that deadline. Any event that you want to make an adjustment to something, you'll have that opportunity. Otherwise there is a real possibility that you won't even know if you passed the course until after the course has ended, if you waited until the final couple of days to submit. So if you submit on Wednesday, remember the assessment faculty will have three. Days to to, you know, grade your assessment. I mean to give your assessments, right? So your deliverable could not may not be graded until after the course has ended. So I would not put myself in that position and I really want you guys to think about that in advance of that time frame and plan in advance so that. You don't find yourself in that situation. If you have any questions about the deadline for the course or you know what is necessary for you to, maybe you've got an R and you want to know. You want to get more clarification or more clarity on what you need to submit in order to improve that R because you remember any Rs that remain in the grade book after the course has ended. All submissions have been made. You will see an F automatically. That R will turn into an F Otherwise, an R again is not a grade. OK, it's just a placeholder. All right, so let's look at the presentation objectives. I'm gonna review and discuss the previous deliverables, as we always do, because in this particular course you are. From. One deliverable to the next. So you're starting with module one to module 2 because the information you need in module 2 is going to be predicated upon the information that you have in module one. So you really want to make sure that you really it's dependent on that. I should say it's dependent on that information. So you want to make sure that you are doing these. Deliverables in order. The only deliverable in this particular course that's independent of the other deliverables is deliverable 7. So if you want to jump ahead and do it and then go back, that's up to you. But that's how you're working. Most often you're working laterally in this particular course. We will explain the linkage between each deliverable, as we always do, because I think it becomes a lot clearer once we start talking about how this fits with the previous deliverable. So most students are getting that that aha moment, you know, and so most students will tell me now I understand why. We had to work laterally and so on and so forth. We're going to also discuss the current deliverable requirements obviously, and we're going to outline success strategies for the remaining weeks in the course, which I know it seems like we have a lot of weeks remaining in it and on paper that's what it looks like, but when. When you look at, when you think about the time that between now and the end of the course, we are already into February, you know, so we really don't have a whole lot of time. So you even though it might appear that we do, when you think about it, the time goes by really quickly. All right, so let's connect the dots. So in deliverable one, you were asked to look at a community health needs assessment, look at the demographics within the community and and all those factors, right? So one of the things that you want to do is look at the community health needs assessment. And decide among many of the choices that you have available to you, because all communities have various needs. You cannot fix everything in every community. So you were asked to look at the community and choose one specific topic that you want to address 1 specific. health-related issue so that your organization can build a population health management program to support the community based on that one specific health topic or health issue. Then you were going to look at the demographics, talk about the demographics in that community. Then you're going to develop key performance indicators or KPI S because once your organization has decided what we're going to look into. Doing this particular type of program, but the organization's going to say, but we want to know how do we know we're successful at it? How do we know when we've met some success with it? Because otherwise they're just going to be throwing money at something and they don't have any way to measure it, right? And I've always told students if you cannot. Me. You cannot improve it. So your whole idea is to improve the situation for individuals within a particular community based on the community health needs, right? So once you've decided, well, in this particular community, they really need help with this particular health related issue. Maybe it's teenage pregnancy. Prevention because maybe they're higher than the national average. So if you've decided that that is your focus, that's your focal point, then what you would do is then determine how will you know what measures will you put into place to know that your organization is achieving the goals that they set out to achieve. So that's where your key performance indicators come. All right. So in deliverable 2, now that you know what program from deliverable one, you know what type of health population health management program your organization is going to determine is necessary for this particular community based on a community health needs assessment. And you also know how you're going to measure success with your KPIs and that. That was module one. So in module 2, what you are going to do now is say, OK, we know what program we want to invest in for this particular community. Now we need, I need to make sure that the powers that be understand why this program is beneficial to this community. So I'm going to look at data that will tell. tell me that this program could be supported in this community. OK, so so if you're looking at a teenage pregnancy prevention program, you certainly don't want to go to your to your your organization and say, well, 95% of the people in this community are are beyond. childbearing age, then that means that that community could use other things, but it would be not the wisest investment for your organization when there's only 5% of the community of childbearing age. So your teenage pregnancy prevention program, while 5% maybe teenage. But. So you know, you could do, you could use a lot. You could use your resources in a lot of different ways as an organization. So what you want to do is again, you want to find a a need in the community where it's going to be beneficial. That's why you want data, because you want to make sure that even though it looks like something is needed in that community. Let's look at the data to see if the data is there to support the program that I'm trying to counsel my organization on developing. OK, so that's what you'll be doing in deliverable too, looking for data sets, any type of data that's going to support the need for your program. All right, that'll justify your need for your program. OK, so deliverable 3. Now that you know what data you're going to need, you're going to be explaining where you're going to get the data from. So where am I going to collect this data? If I want demographic data, I want to know what the age, the average age of people in the community as a data set if I want to know. that, I'm going to have to know where I'm going to get that data from. Most often you're going to find that the community health needs assessment, because they've already conducted this information for you, use the community health needs assessment and you will be able to collect that that type of information. So your source would be the community health needs assessment, right? And you're going to be discussing that in great detail. Detail for your deliverable 3. Deliverable 4 is where the fun begins. This is really this is probably my favorite part of it all. You're going to now take the data that you've decided you're going to need in deliverable 2 and you're going to present that data. In a visual way so that your organizational leaders can say, oh, OK, so I see that we have a national, the national numbers of teen pregnancy is lower by 20% and this community has a higher rate of teenage pregnancy by 20%. So that definitely supports the need. For a teen pregnancy prevention program, but you have to also make sure you have enough teens in the community that will say, I mean that will that will show, that will demonstrate that there's enough teens that will participate in the program. So that's what your data dashboard is. It's your visual depiction of the issue. So first you're going to decide what type of program based on the community health needs assessment is going to be something that you would recommend your organization doing. And you're going to say, and this is how we're going to know we're successful by these key performance indicators. Then you're going to look for what data is going to support or suggest that this type of program is going to be beneficial. Then in deliverable 3, you're looking to see where am I going to get this data from, OK? And then in deliverable 4, you're going to display the data. So that's what your 4 deliverables that we've already completed is all about. All right, so as an example, deliverable one, and I know it sounds like a broken record, but I want to make sure that everybody understands it. And I and I do still get questions about what is this? How is this connected? What does this all mean? So I want to make sure that everybody feels supported. OK, if you understand it. Just bear with me. But for those of you who are still trying to put the put the pieces together, I'm always going to make sure that you guys understand. And whatever it is that I need to do to support your understanding, not to promote any way of developing your understanding is what I'm going to do. So that's why you see I will bring these. Up in every single live session. So deliverable one. Let's just say you're in a community that shows that there's a high percentage of individuals who are being diagnosed with HIV or AIDS. So your so your first thought is, well, maybe we can make an impact. In this community, a positive impact on this community by offering an HIV AIDS prevention program. So you will what it what you will look at is your KPI. So what KPIs are going to keep performance indicators are going to tell me that this program is working right once we implement it. So the number of HIV tests conducted is a key performance indicator. So if you get more people testing, that's a key performance indicator. And even if you get fewer people testing, that's still a key performance indicator. It just means that you may have to do some something more, more marketing, more tweaks. or whatever your your program to draw these individuals in, you have to do something in order to increase the number of people getting tested. If you see that there's a great deal you know where people are starting to get, more people are starting to get tested, you want to continue to build on what it is your program that you're offering. and the marketing efforts to get people to continue testing. So what it measures is reach and uptake of HIV testing services. That's the number of tests conducted. Why this matters? This matters because regular testing is the way to have early detection and linkage to care. So it helps to reduce the rate of transmission because sometimes people don't always understand how HIV or AIDS is transmitted. So by having a HIV AIDS prevention program, you're being you're able now to teach people ways to avoid transmission of it. If the person knows that they're HIV positive, you give them skill sets, give them information so that they know ways in which HIV AIDS is transmitted and they know how to avoid that. So an example of a KPI might be the percentage of targeted population. Being tested for HIV in the past 12 months. OK, so that's maybe your key API. All right, so the data sets needed. The number of HIV tests conducted, the number of condoms distributed, the number of individuals who acknowledge using condoms during sexual intercourse. So those are three data sets right there, OK? Data sources. It could be your CHNA, your Community Health Needs Assessment, the Census Bureau, the American Community Survey, the National Center for Health Statistics. All of these have data. So these are your sources of data. OK, so if you're looking at the. Number of HIV tests conducted your You could find that information from either the Health Center and your local area. You might also find that in the community health needs assessment. So wherever you could find the data, that's your data sources. And then the dashboard. So this is what a dashboard would look like for HIV, right? So if you look at it, there are many graphs there. There's a lot of data there. That's because in deliverable two, you would have decided which data is necessary. Now you're just going to put it on a visual display. So when you present. Sent this whole package to those individuals in the organization that's going to make the decision whether or not, yeah, we might go along with the program that you're recommending. They're going to want to see the data and and in in a real visual way, OK. All right, so if you have any questions, please do not hesitate to reach out. So there are some resources that are available to you. Tutoring services are available to you. However, what I highly recommend for you is if you have questions that is specific to the coursework because the. Coursework is so specified, you might want to reach out to me, but you can always reach out to tutoring. OK, also library assistance and the Writing Center. Those are all all available to you, OK? All right, so let's look at Module 5. So the competency for Module 5 is that you will evaluate sets of health data from diverse populations using population health management principles. All right, so let's go to the scenario. So the scenario goes, effective population health management programs require strategies to reach the individual consumer or patient at all stages of life in the manner that's most appropriate for each individual. So population health management strategies. Will include a communication strategy where you're reaching to those consumers. So when you're looking at your program that you're implementing, think about how you're going to get people to participate, how you're going to reach those individuals where they are. OK, so population health management must use a set of patterns of population health strategy. That describe people and their preferences. So think about it like this with your if you are doing the HIV prevention program, OK, let me just tell you, because of the sensitive nature of HIV, preferences have to be really taken into consideration, like for instance. Will they want communication through e-mail? Will they want communication? Will they be willing to come to your location to be tested? Things of that nature. OK, so these pattern classifications help healthcare organizations begin to understand how they should develop a robust population health management program. Program that serves the population's needs. So the bottom line is you've got to make sure that you're meeting the needs of those individuals that you are targeting. So these patterns classifications help healthcare organizations to begin to understand by grouping people into patterns or segments. Healthcare organizations can then analyze and predict the needs more effectively. Think about again that example of the HIV positive patients, individuals, if they're learning how to. You know, transmission dangers, if you will, of HIV or if they're participating in risky activities that will put them at higher risk for HIV. So you want to make sure that you are looking at those individuals, analyzing and predicting their needs any and. Effective. in advance, right? So how they should develop a robust population health management program to serve the population needs. So if you understand what those needs are, it'll allow you as an organization to build what is going to be used, a program that's going to be utilized, right? A strong, targeted, and effective population. health management program because people will recognize the fact that you're helping to serve their needs. All right, so examples of population health management strategies include individual behavior strategies, clinical population medicine strategies, health equity strategies, continuous And provider engagement strategies. So any of your programs can fall under any of these types of strategies, but you will know based on the fact of the type of program that you're recommending. Patterns of population health management strategies are really just effective ways of making sure that you get the message out to. To those individuals and making sure you're building a program that's going to be used. So each market and population is unique as you know more when you look at market position, service offerings, health status, predominant diseases and geographic and community features, those are all unique factors that has to be addressed. That's the reason why you wanted to do the community health needs assessment because you're looking. Looking at individual communities and looking to serve those particular communities needs. OK, every community you can have a community that are is adjacent to each other, but they may have very different needs, OK. As your healthcare system gains a greater understanding of their local population needs, the Population Health Management program that you're going to be developing needs to develop criteria that will be assigned to specific population cohorts to define the various proactive health interventions and care delivery. K. So you're going to be writing an executive summary that would that's what your output will be for this particular deliverable. You're going to write an executive summary where you're analyzing the various patterns of population health management that your health system is developing for the diverse population. OK, you're going to need to include at least five quality references. So that you can support the assessment of your findings. Now, the importance of population health management cannot be understated, right? You have to be very careful not to understate it. So population health management programs. These are systematic approaches to making sure that you're addressing the preventive, high risk and chronic needs of patients. The goal should be to minimize costly interventions, like keep people away from the emergency room, keep people away from hospitalization, keep communities from experience. seeing transmission of communicable disease by offering information that's going to be helpful. OK, so you will have an introduction. In your introduction you should include specific information that that also includes statistics about the cohort and the specific disorder. So this is an example. Here is what will be included in an introduction. So obesity is a complex phenomenon. So if you're. Program is going to be targeting obesity. This is what it might look like. So again, obesity is a complex phenomenon that has a wide-ranging effect on the everyday life of all populations, according to the South Carolina Department of Health and Human Health and Environmental Control, or what we refer to as DEAC 33.7. 7% of the children in the state of South Carolina is considered overweight. So this is something that is going to be helpful for you to present to your leaders in the organization to say, well, listen, this is the reason why I think this program is going to be beneficial. So if you're someone who's going to be doing a childhood obesity prevention program. program. What you would do then is talk about the statistics. You talk about, like for instance, in South Carolina, if you're trying to develop it in South Carolina, give them the facts so that they will be able to understand why you feel so strongly that this program is going to be beneficial and going to be utilized. So to break it down, effective population health management requires strategies, which is nothing more than a plan of action to reach the individual consumer or patient at all stages of life in a manner that's appropriate. OK, so it's about a defined group of individuals. So in this particular case, the example I just shared was childhood obesity. So you want to make sure that you're looking at targeted, focused and forward-thinking ways of supporting these individuals with your population health management program. So you want to use a set of patterns of population health strategies that describes the people in their. Preferences. So it's about the individual and what works, what will make those individuals participate in your program. OK, so preferences matter and people matter. So let's look at an example. The prevalence of type 2 diabetes in children and adolescents is high in comparison in Charleston, SC to. Other comparable cities in the United States. So a strategy might be more clinical trials, added endocrinology services, nutrition, education, exercise or get moving campaigns. These are all strategies, you know, individual different strategies. These are just suggested strategies, right? Telehealth and using the continuous patient and provider engagement strategy. So that's remember we talked about that strategy. Let's see if I can find it here. So these are some strategies here. In this particular case, it really it was more appropriate to use the. Continuous patient and engagement provider engagement strategy if you're going to be doing these types of activities. So patterns may include increased challenges, maintaining blood glucose levels, acute admissions due to lack of understanding of factors that contribute to spikes in blood glucose levels. controllable blood glucose levels due to lack of access to primary care, might be transportation, or just might be lack of mobility capabilities for individuals. Want to include SMART goals? Make sure your your goals are specific, measurable, achievable, relevant and time censored. So just to look at the SMART goals here, childhood obesity impacting children between the ages of 10 and 17. So to reduce these are SMART goals reduce. Obese. Rates for children and adolescents. That's not enough, right? So what you want to do is you want to say by 20 by December 31st, 2025, reduce the percentage of obese 4th graders from four to six, I mean from 6 to 4%. What that does it lets it, it makes it more measurable because you have more quantifiable. Quantifiable variables there, right? So instead of saying increase participation in nutrition and exercise program among senior citizens, you want to make sure that you're giving some time to it. By December 31st, 2025, increase the percentage of seniors participating in the Get Moving campaign. Very specific from 14 to 16%. OK, so that's what your SMART goals will be measurable. So with the rubric is going to, this is how you're going to be graded. In terms of the rubric, you're going to analyze the various patterns of population health management using the information that I've just shared with you with specific examples and fully developed reasoning. You're going to incorporate 5 quality sources in your work. Your executive summary really needs to be laid out in terms of discussing the purpose. What is the purpose of your program? What's the problem your program is addressing? What is the data? What can the data tell you and what? Can be changed or improved and what's the results? What makes you think that? What is your result? What is your conclusion and your recommendation? So that's basically what you will be covering for this particular deliverable. If you have any questions whatsoever, please do not hesitate to reach out. I look forward to those questions. And I look forward to seeing where you're going to go with your Population Health Management program proposals. So thanks everyone and I look forward to hearing from you all. Thank you.

Merle Point-Johnson stopped transcription