Population Health: Improving Systems, Practices, and Outcomes SCOTT CONFERENCE CENTER OMAHA, NEBRASKA AUGUST 3, 2016

Triple Aim

What is Population Health? It focuses on improving population health outcomes A widely accepted definition is “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” (Kindig and Stoddard, APHA, 2003) Unfortunately, this definition can be interpreted in different ways

Views of Payers, Providers, and Public Health Professionals Payers tend to view the defined population as their current enrollees or covered lives Providers tend to think of the defined group as their organization’s panel of patients – Often called Population Health Management Public health professionals tend to view the defined group as the entire population living in a geographical area (e.g., a city or county)

Population Health from a Public Health Perspective A broader perspective implies that the determinants of health and health disparities be addressed Also implies that policies and interventions target the determinants

What Types of Services Are Considered Population Health-Oriented? Initially, payers and providers tended to think of population health services as clinical preventive services provided in a physician’s office Immunizations Screening for colon and breast cancer Counseling for behavioral risk factors (e.g., tobacco use and obesity)

Population Health Services Expanded Beyond the Clinic Delivering messages by telephone or computer to targeted patients to reduce hospital readmissions Providing home visits by a CHW or community health nurse to reduce risk at home, improve medication compliance, and/or provide direct assistance Promoting community or public health services such as lead testing, disease surveillance, improving access to fruits and vegetables, and walkability of communities

Challenges of Population Health Which populations should be targeted (broad versus narrow)? Which prevention/health promotion strategies and services should be emphasized? Which measures should be used to track progress? In the past there was not a coordinated effort, but there are now strong incentives to work together

Motivation to Address Population Health Issues CLINICAL PROVIDERSPUBLIC HEALTH Reimbursement tied to quality and reducing costs (readmissions, ED visits, cancer screenings) Fulfills mission of keeping people healthy Desire to improve health of their patients Opportunity to address social determinants Better tools available (EMRs, risk management, etc.) Better tools now available (Big Data, collective impact techniques, etc.) Greater willingness of partners

Strategies for Moving Forward Improving population health outcomes requires better coordination and ideally integration of public health and clinical care The morning session will explore population health from both clinical and public health perspectives, including roles and responsibilities, strategies employed, and some potential barriers The afternoon session will focus on the role of “Big Data” in improving population health. It will also involve how Big Data can improve strategic decision-making at both the clinical and community level