1. Carmen Francavilla, MBA, BSN, RN-BC, PCMH CCE Director Population Health Ascension/Lourdes

2.  Define population health  Understand the progression from fee for service to value-based reimbursement  Identify opportunities in care settings to apply population health strategies

3.  2001 -Institute of Medicine (IOM) released “Crossing the Quality Chasm: A New Health System for the 21 st Century”.  Healthcare in the US unable to be sustained and achieve quality outcomes  Requires complete transformation  Three principles  Improve the patient experience of care  Improve the health of populations  Reduce the per capita cost of health care

4.  Many definitions – Guiding principles – Triple Aim  Evolving focus on population of patients  Correlation of health outcomes and social determinants that influence outcomes  Driving healthcare payment reform

5.  Healthcare marketplace changing due to financial incentives in the ACA  State reform – DSRIP  Commercial payers shifting to risk-based contracting  Fee for service – based on volume  Value-based – based on outcomes of care

6.  Requires integration  Medical care  Public Health  Social Services

7.  Prevention and Wellness  Disease Management  Across the lifespan  Understand social determinants of care and influence on health

8.  EMRs and Claims Data  Organizations need the capability to analyze data  Data and analyze assist organization in setting priorities and targets for improving health

9.  Patient Engagement ◦ Patient-centered care  Provider Engagement ◦ Team-based approach to care  Community Partnership ◦ Integration of community resources  Organization Commitment ◦ Infrastructure changes to support population health

10.  Infrastructure Changes  Culture Shift  Physician Leadership  Communication and Education  Healthcare Delivery Transformation  Continuous Quality Improvement

12.  Across the Chasm: Six Aims for Changing the Health Care System. (n.d.). Retrieved May 17, 2016, from http://www.ihi.org/resources/pages/improvementstories/acrossthechasmsix aimsforchangingthehealthcaresystem.aspx  Moving Toward Population Health: An Interview with David Nash, M.D., MBA. (2015, January). Retrieved May 17, 2016, from http://www.hanys.org/population-health  Tipirneni, R., MD, MSc, Vickery, K. D., MD, & Ehlinger, E. P., MD, MSPH. (July/August 2015). Accountable Communities for Health: Moving from Providing Accountable Care to Creating Health. Annual Family Medicine, 13(4), 367-369. doi:10.1370/afm.1813