Deliverable 6 - Chronic Diseases and Population Health Management

Live Class Recording M6 - HSA5300

February 10, 2026, 11:01PM

31m 51s

Merle Point-Johnson started transcription

Merle Point-Johnson 0:03 Population health management program. I'm sorry, course. OK, so you are building a program for a population health management for a particular condition that you've already pre-selected. OK, so I'd like to start with a motivational quote and a motivational quote offered for this particular deliverable or this particular module will be healthcare is vital to all of us some of the time, but public health is vital to all of us all of the time and this. Is from C Everett Coop, who used to be a Surgeon general for the United States. OK, so let's look at the presentation goals for this particular module. We're going to examine key elements in successful disease management and population health management. We're also going to explore risk factors that affects population health management. Management as well as disease management. We'll review the deliverable requirements for this being your final deliverable that is linked to all other deliverables. Deliverable 7 will be a little bit different because it is not dependent on the other deliverables. Is more of an independent deliverable and we'll just talk a little bit briefly about the course and of course deadline. OK, so let's just talk for a moment about episodic care. That's what we're used to in this in the United States. We're traditionally or historically, we've always delivered care based on episodic care, meaning that if you are sick, you get care, you seek care. OK, so it happens when a patient seeks care for a single illness, a single injury, or based on symptoms that the patient is currently experiencing. Care ends once the immediate issue is treated. So if someone goes and experiences. Is some type of allergic reaction. They go to the emergency room or to the primary care doctor and they receive treatment for it and then that ends it. That's what episodic care is about. So there's no real need for follow up beyond that particular episode because the issue has. Has been resolved. Where population health management comes into play, it is improving the health outcome for a defined group of people. What is used in the health? This is longer term. It uses data for evidence and ensuring that they're looking at evidence-informed decision-making. where it comes down to taking care of individuals. And this evidence is used to identify health risk. You know Is this person at greater risk for whatever? It also includes coordinating efforts across primary care, tertiary care, secondary Care, an urgent care setting. So if you go to the emergency room, your care is coordinated. Maybe the emergency room physician will say follow up with your primary care physician. Information is shared and that's how you are treated. Addressing social behavior and environmental factors. These are those non medical factors that we refer to as social determinants of health that also impacts a person's ability to achieve health status that is optimal. Also, we measure outcomes and continuously improve using intervention that we know is going to be based on evidence, intervention that we know works, or addressing those intervention that has no impact or has Negative implications for the patient. So we're shifting from where you see the episodic care and we're moving more towards population health management. And the reason why we're doing that is because the net result is so much better. So when you're looking at rising chronic disease rates, more people are developing chronic disease that could be environmental. There are so many other factors that come into play with that. So that's the reason why we're shifting and not just looking at it from one episode to the next episode, which automatically is going to be. and less effective health high health care costs. We're shifting because we know that population health focuses on prevention. And we also realize through many, many, many, many. Empirical data and studies that when we are dealing with a with prevention, we can save money in the long run. So health disparities across communities. So one of the goals of the healthcare system and through healthy people initiatives, we really are focusing. Quite heavily when it comes down to reducing health disparities and creating more health equity and movement towards value-based payment models where patient centricity is the key. So we're moving away from those volume-driven care models where where episodic care really lives. We house it there, but we move forward and we're looking at value-driven care models and that is more aligned with population health management. So there's some benefits to having population health management focus and that's improved health outcomes. That's the ultimate is you want. To improve the patient experience and improve health outcomes, you want to reduce emergency department visits and hospitalization. Those are your more costly care, and you want to avoid that if at all possible. So reduction in that will require that you're looking at a population health strategy. Lower cost overtime. So as time initially there might be a heavier output, but overtime cost is really going to be diminished. Better patient experience and greater health equity now. Disease management, on the other hand, is really like a specific condition that you're focusing in on. So and it could be diabetes, asthma, hypertension, heart failure, anything of that nature. But the bottom line is you're focusing on people who already have a particular condition. So it's not prevention, it's maintenance and prevention of further, you know, deliver. Problems. OK, all right. So population health. When you look at the two side by side with disease management, population health, population health asks the question, why is this population getting sick and what systems need to change in order to improve outcomes? So obviously answering. Those. Questions gives us a broader spectrum from which we can work. OK, disease management. And again, it looks upstream, right? But disease management on the other hand, as how do we help people with this condition? So as you can see, there's a different focus. So you're looking at a. population versus an individual or individuals with that condition. And you want to also teach those individuals how to better manage it so that they don't go into the next level of care needs. So it's typically condition specific. Clinically focused and ongoing and structured. So that's what disease management is. All right. So in this particular module, you're going to have the competency of developing a population health plan. Where you're going to be addressing a health concern, you've already identified one in the current health care industry. So the key to effective and sustainable population health management program is to know your chronic disease patients and to coach them. So let's look at the scenario. So the scenario is basically this, the success of population health and chronic disease management efforts. Those hinge on a few key elements. You have to 1st be able to identify your risk, and this isn't anytime you're trying to manage anything if you don't. Identify what the challenges are, the risk of those challenges. It's going to be really an uphill battle for you to address it. So you want to have access to the right data about them, making sure that you're getting quality data, data that's valid, data that's reliable. So that you can make the better decision. So it's like in the old accounting days, garbage in, garbage out. Same thing here, right? You want to make sure you have good quality data from what you're basing your decisions on, creating actionable insights about patients, things that you can act on, OK. And coaching them daily toward healthier choices. Sometimes it's just a matter of educating individuals and populations, knowing that your body is made to move. So knowing that individuals who sit behind a desk like myself for a. Large part of the day. You really want to make sure that those individuals understand the implications of limited movement. So exercise is key. The amount of water you drink is key. The amount of sleep that you get, OK. Again, chronic diseases are very expensive. Diabetes people don't realize how expensive diabetes care is because if you develop diabetes earlier on, you've got it forever. So bottom line is you're going to be continuing to fund that care for a very long time. So hypertension is. An expensive disorder because it's connected to so many others, and depression is also OK, so those are some chronic diseases. So breaking it down, you have to define your target population. So you guys have already done that by looking at your deliverable one where you have decided. You've decided what, based on the the community health needs assessment, you've decided what population of individuals you'll be serving in terms of your proposed program. You're going to develop the criteria, and you've already done that as well, because you've already said what your KPIs will be, what your goals are going to be for that program. You've already decided what data set you're going to be using and where you're going to get your data from. You've also depicted it in a visual, which we call a data dashboard. So you're going to educate, inform, critique, and evaluate your program. So key elements where it comes down to successful population health management and disease management programs. Again, you have to identify those individuals who are at risk and that's again where your community health needs assessment comes into play. So you have the access to the right data about those individuals. You're going to create actionable insights about the patients and coaching them daily towards healthier choices. That's the whole reason you're developing it program, because you want to be able to offer ongoing continuous coaching to individuals. So when you're developing. Developing a population health management program. So you're doing a teenage pregnancy prevention program. Then that means you're giving information. You're increasing the health literacy of a group of individuals who you've identified is at risk for becoming for experiencing teenage pregnancy, unwanted teenage pregnancy. Unplanned. OK, so population health management shifts from process-based care to patient-oriented outcomes. That's what population health management does. And disease management is based on the chronic care and the models that are used and the aims that they are expected to achieve to. Improve quality and care delivery. Hi. So disease management really grew out of the attention, the 8020 rule that we hear so much about and it's the truism that 20% of the population is really going to account for 80% of the cost. So we know that there's that 8020 rule and. And we've been for many, many decades been trying to have that positive impact on that. Well, the population health management and disease management programs will focus on those things. So the focus of disease management is really on chronic conditions. Those mostly affect large numbers. Beneficiaries like for instance, we know that there are a large number of people are going to develop diabetes and that is if you look at diabetes management, right, you're all they're already got it right. They have like either pre-diabetes or they have diabetes where population health management if you're looking at it on on the other side. You're developing programs that says if you do these things, you are going to decrease your risk significantly of developing this particular condition. So some terms that I want you guys to get familiar with, terms that I use in my everyday work, is risk stratification is such an important way to look at this. When you. Looking at population health management, it is a systematic process where patients risk levels are identified and patients and predicted and patients are categorized as such. So we know that a one-size-fits model does not work. It's cost prohibitive and it's very, very. And effective in terms of clinically treating patients, right. So the goal is to identify those patients who had highest risk and prioritize the care for those patients. And it does enable for interventions that are customed or tailored to the individual needs. Of those individuals and it improves overall patient outcomes. So risk stratification is just basically grouping those individuals. So you see here, if you look at this diagram, you have the level 1 to level 5, OK, so you go from level 1234 and five and then each one of these will have the goals, the access and who's responsible and any type of resource. That are necessary. So when you start at level one, you realize that you're not going to need as much resources as you would when you're at level 5. So these are the categories and they're very, very explicit. So you you have like very small percentage of patients in a highly complex case. That's your priority when you're looking at stratification and deploying resources, right. So this is a group of patients with the greatest care needs, more complex. Complex patients. This group, less than 5% of the population, has multiple complex illnesses, comorbidities, and they include sometimes psychosocial concerns and barriers that really impacts the patient's care. Individuals who have who suffer from Alzheimer's or dementia and there are psychologic, psychosocial factors that may impede their care, right. So you have high risk. These are 20% of the population. The goal is to keep those high risk patients from. Stepping up into the high complex patient category. So the high risk patient is that next level down tier and you'll see again it's about 20%. And if you leave these individuals unmanaged, if you leave their care unmanaged, they will achieve the higher complex case and that's not where we want them to be. Then you have the rising risk patients. These are individuals who have one, perhaps more than multiple chronic conditions or risk factors, maybe not even developed yet into that chronic condition, like those who have been diagnosed with Friday or doctor as pre-hypertensive because. They've had elevated blood pressure readings over a period of time. So the doctors really like watching their progression towards hypertension and offering the least intensive care type of services for them, like maybe exercise. Regimen, maybe nutrition, you know, just to avoid them going into the next level, to the high risk level. OK, so they are, they move in and out of stability. So the doctor might see them one month and their numbers are where they need to be, see them the next month. So they go back and forth, but the goal is to keep them from moving up. And then you have those who are low risk. These are individuals who really seek preventive care only. That's all they really need. They're really stable. They're really healthy. Usually they're in a younger category in terms of age, usually not always. But this is a group that this is where you, this is where you want your. The bulk of individuals to be. So this is what a risk stratification chart may look like. I'm not going to go through all of that, but I just wanted to share what it might look like. So you have to look at again prioritizing highly complex, high risk, rising risk and low risk. So at risk populations are those individuals who are considered to be most vulnerable. These are individuals who oftentimes will have lower. Literacy where it comes to health because they may or may not understand their regimen. So it's not always low health literacy, but most often it does result from those patients with low health literacy. You could be a an astronaut. You can be a rocket scientist. You could be all, you know, nuclear engineer. OK, very smart. But when it comes to health literacy, that's what we're focusing in on. We're not saying that these individuals are by any means less smart. It's just that their health literacy is low and 9 out of 10 people. In the United States have held some health literacy challenges, so it may be defined by race, ethnicity, gender, primary language, and etc. All right, so health disparities. The health disparities are usually impacted by a person's education and access to the quality of education, because not all educational achievement is going to be easily accessible and not all will be equal in terms of quality. So neighborhood and the both built environment. Think about the neighborhoods, right? Are there any opportunities for individuals to experience any positive where it comes down to growing their own gardens? In the community, social and community context, that's another factor, as well as economic instability, poor health care and quality. So not everyone receives the type of health care quality. That everyone deserves. So identifying those who are most at risk, these are individuals are typically with some combination of tough chronic diseases, complicated behavioral health issues, and adverse social conditions. If you put those three together, that really does give you a. Really pretty picture of understanding gives you a nice idea, puts things into context and gives you an idea of what is necessary in terms of how you address those individuals. These individuals are more likely to create a strain on the health care system. Often these individuals don't seek medical care until. Care is absolutely essential. They require treatment from various providers and significant investment in resources. So that goes back to that 8020 rule that I talked about before. All right, so let's look at the instructions. So as your health system is drafting A strategic framework for. Population Health Management program, and that's what you've been doing since you started the course. Since module one through module 5, you've been building on that program that you've already identified will be your program. So that's your strategic framework. OK, so you're being asked to create a PowerPoint for. Presentation with detailed speaker notes. Now you have to have speaker notes in this particular instance. Now if you're going to be using any platform other than a PowerPoint, you know the PowerPoint, Microsoft PowerPoint, maybe you're wanting to use a different software. Maybe you want to use something. Screencast-o-matic, which is perfect. Make sure that you are submitting in addition to your your your video, submit what you call it, just the the notes, the transcript. That's what I'm trying to get out. Submit your transcript as well if you're using. PowerPoint. You can actually put the notes on the bottom of the PowerPoint presentation because there is a designated area, which most of you probably familiar with, but there's a designated area on each PowerPoint slide. So each one of your content slides should have information on it. Now if you're going to use PowerPoint, you cannot save it as a PDF. Because if you do so, your assessment faculty is not going to be able to read your speaker notes. So save it as a PowerPoint or submit the the speaker notes with it as a transcript, and that's perfectly fine to do. So explain the relationship between disease management and population health needed in the following areas. So you're going to describe the prevalent chronic diseases for the population your health system is serving. So think about remember you started off by looking at your population health management. I'm sorry, your the community health needs assessment. Within the community health needs assessment, it discussed chronic conditions as well. So you're going to go back to your community health needs assessment and just look it up because the information is going to be provided for you. And So what you're looking up is what chronic disease. Challenges that this particular population have in this particular community, even if it's not necessarily like for instance, if you see that in that particular community, they have a lot of asthma, so that's a chronic medical condition. Even though your program may not be asthma related, you want to discuss your that program. No, I'm sorry, you want to discuss that condition, that chronic medical condition. So just you're looking at what other types of chronic conditions are affecting that particular community. In which you're you're focusing in on. OK, so you want to talk about the prevalence of the commonality of the disorder. So how common is that disorder? And so if, for instance, you you like if you're doing childhood obesity. You want to talk about things in the community like hypertension, you know, is that a chronic medical condition in that community? The reason why you're doing this little exercise is because what you're going to do is highlight how whatever your particular condition is, right, that you've decided that you're going. To focus in on, let's just say you're focusing in on teenage teenagers who are obese or childhood obesity. We know that that plays a role in developing hypertension. We know that plays a role in developing kidney disease. We know that that plays a role in developing diabetes. So if that community. has those conditions, go ahead and use that. Does that make sense?

Stefini Mccord 25:19 Yes.

Merle Point-Johnson 25:20 OK, cool. So you're just trying to see you know how what other conditions you want to discuss that may be impacted or your your population health management program might impact. So hopefully you have a population health management program that will actually decrease some of what those. Um. conditions are. So I'll give another example. If you have a, if you're focusing in on teenage pregnancy, what we do know is that individuals who are, um, who are pregnant teenagers, sometimes they're at a higher risk for gestational diabetes, right? And just because you develop diabetes when you're pregnant doesn't mean it goes away when you're no longer pregnant. So that diabetes would be like a um a feeder type of disease, if you will, chronic disease. So that would align with your teenage pregnancy focus. All right. So, OK, so you want to describe the risk that is associated with the proliferation of the chronic disease. And this is where you can make that connection between your program and the chronic diseases that appear in that community. For example, what is the risk factor for developing obesity? Sedentary lifestyle, dietary choices, metabolic conditions. So we know that if you're focusing on diabetes, I mean on on obesity, we know that it leads to individuals being at a high risk for stroke. For high blood pressure, for for even mental related conditions like just starting to live a sedentary lifestyle due to depression or anxiety, whatever, right? So you get to connect the dots there. So you're gonna assess how the population will access information and resources to prevent and manage chronic diseases. So in this case, you know, what is your communication prevention strategy? So if you are, for instance, go back to the teenage pregnancy example. So if you're gonna be discussing. Gestational diabetes and how it can turn into diabetes. So how are you going to communicate that so that your population understands the risk associated? OK, how will you address the management of the disease among targeted populations? Will you recommend something like nutrition or exercise programs, something of that nature? So when you're developing a population health management program, you want to make sure that you're reverting back to module one so that you can really. Identify how one impacts the other, how your population management program that you're creating is impacted by all of these chronic diseases or impacts the individual's development of these chronic diseases. And again, you want to look for those diseases that are prevalent in the community. All right, so you're going to construct a chronic disease communication plan where this is aimed at helping patients with chronic diseases to pursue healthier choices and to use population health resources. So communication plan might be this. You start off by looking at your audience. Who is your audience? Who you're trying to reach? We already know that because you've already decided who you're going to focus in on for your community, for your Population Health Management program. So you're going to talk about what, what is the messaging going to look like? Is it going to be letters, fact sheets, face to face? Maybe you'll do little community sessions or community symposiums. So, but that's all up to you, whatever your communication plan is. So how you going to deliver that? Is it going to be any? Formal. Is it going to be a formal type setting? Also, you want to schedule it. How often will you do these types of sessions? Obviously, if you're going to be doing a formal setting, you're not going to do that every week. You're not definitely not going to do that every day. So make sure that you're just making it make sense. And then where is the source of that coming from? Who's going to be delivering that? So this is another example of a communications plan. So you want to include your communications plan within your deliverable submission. One of your slides should show your communications plan and your speaker notes should describe it. Alright, so to use your findings from the prior summative assessments. Use and to create your PowerPoint that and that's how I just told you how you connect those two together. So your presentation should discuss the data you collected in the previous models. So for instance, if I presented data in previous week like shows that South Carolina ranked high in obesity, then I should include that. my presentation, but remember we're going to be focusing on chronic diseases, so we know that obesity is a chronic disease. We know that um hypertension is a chronic disease, so we're just linking providing that linkage. So make sure you're reviewing the rubric so that if you have any questions that you can go ahead and pose those questions. Each criterion carefully and make sure you're submitting. Don't hold on to it. As a reminder, you want to submit all coursework by March 20th, Friday, March 20th, 11:59 PM What will happen following our deliverable? Because we got one more deliverable that we hadn't discussed yet. Yet next week we'll be going into deliverable 7, so we have deliverable 7 that we haven't discussed yet, so we'll do that. But once deliverable 7 has been addressed, then what we're going to do is we're going to reset and have everyone let me know what they want, what they want to cover. So I won't come to the. Meetings on the live sessions with anything preplanned because I want you guys to tell me where I can best help you. Any questions?

Stefini Mccord 31:30 I don't with this material, but I do for something else, so maybe after.

Merle Point-Johnson 31:32 OK.

Merle Point-Johnson stopped transcription