1. Population Health Management
Concepts for Health Centers
Module 2
PHM Concepts for Health Centers Module 2

2. PHM Concepts for Health Centers Module 2
CURRENT population health management in health Centers & the case for implementing population health management and addressing the social determinants of health
PHM Concepts for Health Centers Module 2

3. PHM: A Health Center (HC) Perspective
Population Health Management and the use of Social Determinants of Health data to focus care is not new to HCs:
For years, HCs have identified and served the most vulnerable populations with the goal of helping them to manage their healthcare needs.
PHM and SDH are also not new to HRSA, and focus is increasing:
HRSA’s vision, “Healthy Communities, Healthy People” is realized through a focus on Population Health Management.9,10
HRSA integrates PMH and SDH into its strategic plan, which is highly population health focused.11
HRSA’s strategic Goal 3, “Build Healthy Communities” specifically calls for improvement of population health.12
HCs are already being required by agencies including HRSA, CDC, CMS and state Departments of Health and other stakeholders to implement initiatives that integrate a focus on PHM and SDH…
PHM Concepts for Health Centers Module 2

4. PHM Concepts for Health Centers Module 2
Examples of Current HC Initiatives That Integrate a Focus on PHM and SDH
Bureau of Primary Health Care UDS (Uniform Data System)
Many UDS Tables require the collection and reporting of Social Determinants of Health data alongside clinical and operational data. This has resulted in the UDS data being one of the most important national Population Health Management resources:
Zip Code Data
Table 3A: Patients by Age and Sex
Table 3B: Patients by Race and Ethnicity
Table 4: Selected Patient Characteristic including:
Income / Poverty
Insurance
Special populations including Migratory, Homeless and Veterans,
Table 5: Services (e.g., medical, Dental, Behavioral Health)
Table 6A: Visits by Selected Diagnoses
Table 6B: Quality of Care
Table 7: Health Outcomes and Disparities
For 2016, reporting many of the quality of care measures have been aligned with CMS (Center for Medicaid/Medicare Services) electronic clinical quality measures (e-CQMs) to standardize reported data with many other state and national initiatives.
Source: Visit to learn more about Health Center Data and Reporting and 2016 updates.
PHM Concepts for Health Centers Module 2

5. PHM Concepts for Health Centers Module 2
Examples of Current HC Initiatives That Integrate a Focus on PHM and SDH
Patient Centered Medical Home, PCMH (2014)
PCMH is a provider team-based health care delivery model that is intended to provide comprehensive and continuous medical care to patients with the goal of obtaining maximized health outcomes. It is a key component of healthcare reform and can be regarded as a model to transition a Health Center to the provision of value based services.
At the ”heart” of PCMH is a Care Management focus on high-need populations. Health Centers are expected to address socioeconomic drivers of health and poorly controlled or complex conditions, and focus on the special needs of patients referred from the “medical neighborhood” of practices that surround and inform the medical home.
PCMH is the foundation for most state and federal health reform initiatives.
Source: Visit to learn more about the HRSA Accreditation and Patient-Centered Medical Home Recognition Initiative. Visit to learn more about the AHRQ Patient Centered Medical Home Resource Center.
PHM Concepts for Health Centers Module 2

6. PHM Concepts for Health Centers Module 2
Examples of Current HC Initiatives That Integrate a Focus on PHM and SDH
Million Hearts®
Million Hearts is a federal CDC initiative designed to save 1 million lives over a 5 year period.13
The CMS-funded Million Hearts Cardiovascular Disease (CVD) Risk Reduction program seeks to bridge a gap in cardiovascular care by providing targeted incentives for health care practitioners to engage in beneficiary CVD risk calculation and population-level risk management. Instead of focusing on the individual components of risk, participating organizations engage in risk stratification to identify those at highest risk for CVD.14
One of the main components of the Million Hearts initiative is “Hiding in Plain Sight”. Of the 75 million Americans who have hypertension, about 11 million of them are unaware that that their blood pressure is too high and are not receiving treatment to control it.15
Health Centers use a Hypertension Prevalence Estimator Tool to better understand hypertension prevalence among their patient population. The tool generates an expected percentage of patients with hypertension based on the specific characteristics of a health system’s or practice’s patient population. Providers can then compare the expected prevalence to their calculated prevalence—if the values are quite different, there may be patients “hiding in plain sight” with undiagnosed hypertension.16
PHM Concepts for Health Centers Module 2

7. PHM Concepts for Health Centers Module 2
Examples of Current HC Initiatives That Integrate a Focus on PHM and SDH
Meaningful Use
The Medicare and Medicaid EHR Incentive Programs provide financial incentives for the "meaningful use" of certified EHR technology. Health Center providers have to show that they are “meaningfully using” their EHR technology by meeting certain measurement thresholds that range from recording patient information as structured data to exchanging summary care records.17,18
The meaningful use requirements are designed to support and improve public and population health outcomes. By efficiently collecting data in a form that can be shared across multiple health care organizations, it can be leveraged for quality improvement and prevention activities.19
This includes:30
Sharing clinical data between providers to improve patient care
Reporting data to state disease and immunization registries
Using clinical decision support to identify patients needs and ensure the use of appropriate clinical best practices
Reporting national e-CQMs.
Visit to learn more about HRSAs Meaningful Use resources.
PHM Concepts for Health Centers Module 2

8. PHM Concepts for Health Centers Module 2
Examples of Current HC Initiatives That Integrate a Focus on PHM and SDH
Disease and Immunization Registry Reporting
HCs in many states are required to submit disease and immunization data to registries as a key part of improving population and public health. As the ability of EHRs to report and share data improves and Health Information Exchanges become available much of this is becoming automated.
The ability to participate in reporting data to immunization, syndromic and specialized disease registries is a key requirement in the CMS Meaningful Use program in which all HCs are being encouraged to participate.20
All certified EHRs (CEHRT) have the capability to report data to centralized registries in a standardized, nationally agreed, HL7 format and this requirement will be expanded over the coming years.
PHM Concepts for Health Centers Module 2

9. PHM Concepts for Health Centers Module 2
the case for PHM Implementation: Health Equity, the social determinants of health and the affordable care act
PHM Concepts for Health Centers Module 2

10. PHM Concepts for Health Centers Module 2
Health Equity
HRSA has established a strategic goal of improving health equity.21
Health equity is when everyone has a fair opportunity to attain their full health potential.22
No one should be disadvantaged from achieving this potential if it can be avoided.22
Health inequity occurs when differences in health outcomes are systematic, avoidable and unjust.23
Health centers can improve health equity in the communities they serve by mitigating the impact of the social determinants on health and wellbeing.23
PHM Concepts for Health Centers Module 2

11. Equality versus Equity24
PHM Concepts for Health Centers Module 2

12. The business case for health equity23
As safety net providers, health centers are a focal point for caring for populations experiencing disparities.
Health disparities result in poorer health outcomes, excess burden of disease and higher costs for marginalized populations.
Health disparities contribute to financial waste in care delivery: $82 billion nationally in
Patients with lower SES and members of racial/ethnic minorities are more likely to have more complex health needs, multiple chronic health conditions and higher costs.26
PHM Concepts for Health Centers Module 2

13. Population health management and health equity23
Financial risk is associated with health inequity and health disparities
To reduce costs:
Focus on high risk patients
Identify and reduce gaps in care
Meeting value based care targets will be impossible without reducing disparities.
PHM Concepts for Health Centers Module 2

14. PHM Concepts for Health Centers Module 2
An equity framework for addressing PHM and the social determinants of health
Why: Health care centers, because of their safety net mission and ability to reach a vulnerable population, have tremendous potential to directly influence underlying societal inequities that contribute to health disparities and poor health.
Institute for Healthcare Improvement (IHI)
Framework for Health Equity27
IHI provides a conceptual framework and practical guidance to help providers address the social determinants of health to improve health equity and health outcomes.
You can access this framework by setting up a free login at these links:
“A Framework for Improving Health Equity” article, includes a self-assessment:
“Achieving Health Equity: A Guide for Health Care Organizations” white paper
PHM Concepts for Health Centers Module 2

15. IHI Framework for Health Equity27
A commitment to health equity is a foundational step for implementing PHM and SDH. Health centers can:
Make health equity a strategic priority
Develop structures and processes to support health equity initiatives
Deploy strategies to address specific determinants of health
Decrease institutional racism within the organization
Develop partnerships with community organizations to improve health and equity.
Refer to IHI resources for concepts and a framework.
PHM Concepts for Health Centers Module 2

16. Accountability and Value: The Affordable Care Act
2010: with the Affordable Care Act (ACA), policy changes create an evolved and enhanced focus on population health outcomes and population health management.
ACA calls for providers to transform their practices financially, technologically, and clinically to drive better health outcomes, lower costs, and improve their methods of delivery, customer experience and access.
Accountable Care Organizations (ACOs) formed by coordinated providers permit payment tied to quality and cost of care through alternative payment models (value based care).
ACO agrees to be accountable to patients and payors for quality, efficiency and cost.
ACA expands access through individual mandate, Medicaid expansion, state exchanges
PHM Concepts for Health Centers Module 2

17. Accountable Care Organizations
ACO incentives shift the risk to the provider
Provider is responsible for health outcomes for their attributed population
Population is defined by payer – CMS, commercial insurers – and is contract-based
Accountability is shared among all providers caring for a patient
Shared accountability drives the need for Population Health Management
PHM Concepts for Health Centers Module 2

18. The rubber hits the road: Vehicles of the ACA
CMMI – The Center for Medicare and Medicaid Innovation fosters healthcare transformation through support of new value-based models of payment and delivery, to achieve:
Better care
Healthier people: Encourage better health for entire populations by addressing underlying causes of poor health, the social determinants of health.
Smarter spending;
Increased access to and demand for primary care;
Preventive services without cost sharing;
Community-based population health activities;
Community health assessments and community health improvement plans.
PHM Concepts for Health Centers Module 2

19. Impact to health centers
Demand for care is increasing:
Via mechanisms that increase access;
Need to care for a high-demand, high-risk population.
Holding the line on costs through accountable payment mechanisms.
Assumption of risk for outcomes for a high-need population.
Innovative technology and tools are needed to make all this come together.
PHM Concepts for Health Centers Module 2

20. Population Health Management
Population Health Management (PHM) provides the new technology and a suite of tools to:
Assess and improve the health of a population and the individual patients within it;
Identify high-risk patients and care gaps;
Target care resources where they will have the most impact and value;
Measure results to demonstrate value for reimbursement contracting and quality reporting.
PHM Concepts for Health Centers Module 2

21. Rationale for PHM: Value-based reimbursement and risk contracts
Health centers in ACOs and other value-based payment models must manage population health to succeed.
PHM helps mitigate health centers’ financial risk when bearing risk for populations.
The iceberg model: “managing below the water line”28
70 percent of today’s high-need, high cost patients were not in the high-cost category last year.
This year’s high risk were last year’s rising risk patients.
To manage risk, must be able to identify, stay in touch with and improve the health of rising risk patients.
PHM helps mitigate the financial risk of not seeing and therefore not treating next year’s high risk patient.
PHM Concepts for Health Centers Module 2

22. Rationale for PHM: Targeting care and resources to improve outcomes
PHM helps health centers deliver care more efficiently and effectively.
In a value based payment system, the aim is improve patient’s health and outcomes while lowering costs:
Reduce waste
Unnecessary or low-value care, avoidable tests, procedures, readmissions, etc.)
Internal waste from inefficient workflows
Improve quality and efficiency
Understand the population and target the right care and resources efficiently to the right patients so that health and outcomes will improve.
PHM Concepts for Health Centers Module 2

23. Rationale for PHM: Patient Engagement and Care Management
PHM provides automated management and analytics tools to transform work processes and manage populations.
PHM helps health centers deliver care and engage patients.
Data and analytics enable identification of high risk and rising risk patients for application of targeted care.
Tools provide automated outreach to identified patients with care gaps and care needs.
Automated PHM tools help care managers in their work:
Increases efficiency and effectiveness of care managers in engaging patients in their own care.
Permits larger panel per care manager.
Improved chronic care for high risk patients, and better self-care and health behavior improves outcomes and increases value.
PHM Concepts for Health Centers Module 2

24. The PHM value proposition for health centers
PHM technology has value to health centers because:
It can help them deliver better care more efficiently while more closely managing the costs of care;
It can help them manage financial risk associated with caring for their patient population;
It helps them better care for patients with complex health needs who account for a disproportionate share of costs.
PHM Concepts for Health Centers Module 2

25. References
Kindig, D and Stoddart, G. What is Population Health? American Journal of Public Health. 2003;93,3.
Dartmouth-Hitchcock. What is Population Health? hitchcock.org/about_dh/what_is_population_health.html
Dr. John Frank, scientific director, Canada Institute of Population and Public Health.
Young, TK. Population Health: Concepts and Methods. New York, NY: Oxford University press; 1998.
World Health Organization. “Social Determinants of Health.”
Schroeder, S. A. (2007). We can do better—Improving the health of the American people. The New England Journal of Medicine, 357(12), 1221–1228.
National Association of Community Health Centers. PRAPARE
IBM. IBM Phytel Population Health Management.
About HRSA. March 2016.
Healthy Communities, Healthy People: HRSA and the Affordable Care Act. Education/Outreach/OpenDoorForums/Downloads/HRSAAffordableCareActProvisionsupdatedPPTSlides.pdf
HRSA Strategic Plan March 2016.
HRSA Strategic Plan Goal 3: Build Healthy Communities. March 2016.
Centers for Disease Control and Prevention. Million Hearts®.
Centers for Medicare & Medicaid Services. Million Hearts® Cardiovascular Disease Risk Reduction Model July 21, 2016.
Centers for Disease Control and Prevention. Million Hearts® Undiagnosed Hypertension. Accessed November 28, 2016
Centers for Disease Control and Prevention. Million Hearts® Hypertension Prevalence Estimator Tool. Accessed November 28, 2016.
HealthIT.gov. EHR Incentives & Certification. definition-objectives. February 6, 2015.
Centers for Medicare & Medicaid Services. Electronic Health Records (EHR) Incentive Programs Guidance/Legislation/EHRIncentivePrograms/index.html?redirect=/EHRIncentivePrograms/. November 22, 2016.
HealthIT.gov. How can electronic health records improve public and population health outcomes? population-health-. January 15, 2013.

26. References
Centers for Medicare & Medicaid Services. EHR Incentive Programs in 2015 through 2017 Public Health Reporting for Eligible Professionals in Guidance/Legislation/EHRIncentivePrograms/Downloads/2016_EPPublicHealthReporting.pdf
HRSA Strategic Plan Goal 4: Improve Health Equity March 2016.
Whitehead M, Dahlgren G. Concepts and Principles for Tackling Social Inequities in Health: Levelling up, Part 1. World Health Organization, Regional Office for Europe;
Laderman M, Whittington J. A framework for improving health equity. Healthcare Executive May;31(3):
The City of Portland, OR. The Problem with “Equality”
Gaskin DJ, LaVeist TA, Richard P. The State of Urban Health: Eliminating Health Disparities to Save Lives and Cut Costs. Washington, DC: National Urban League Policy Institute; December 2012.
Cohen SB. The Concentration of Health Care Expenditures and Related Expenses for Costly Medical Conditions, Agency for Healthcare Research and Quality, Statistical Brief #359. February
Wyatt R, Laderman M, Botwinick L, Mate K, Whittington J. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016.
Hodach, R. Provider-Led Population Health Management, AuthorHouse, 2015
Arcadia Healthcare Solutions. Risk: It’s More Than a Number April 9, Accessed September 19, 2016.
Clifton Larson Allen. Moving From Traditional Care Delivery Models to Population Health Management. Management.aspx. April 16, Accessed September 19, 2016.
Jeffrey Springer, VP Healthcare Solutions, CitiusTech Inc., Top 5 Emerging Trends in Population Health, September HIMSS and Healthcare IT New Pop Health Forum, Chicago, IL accessed September 19, 2016.
Institute for Health Technology Transformation, Population Health Management: A Roadmap for Provider-Based Automation in a New Era of Healthcare provider-based-automation-in-a-new-era-of-healthcare.pdf?sfvrsn=2
Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012.
Stoto, M. Population Health in the Affordable Care Act Era. AcademyHealth. February 21, 2013.

27. Module 2 Completed Check Out Module 3:
A Roadmap for Implementing Population Health Management
PHM Concepts for Health Centers Module 2