1. A Conversation on Population Health & Wellbeing
Mark Carroll, MD
Brian Gregory, PhD, MBA
Nathan Jones, JD, CHC
May 15, 2017

2. Health care is moving from
“volume to value”

4. The “4th Aim” = Clinician satisfaction or “joy”

5. “The health outcomes of a group of individuals, including
the distribution of such outcomes within the group.”
Kindig and Stoddart
American Journal of Public Health
March 2003

6. “The health outcomes of a group of individuals, including
the distribution of such outcomes within the group.”
Kindig and Stoddart
American Journal of Public Health
March 2003

7. Patient Risk Stratification
“High risk”
“Rising risk”
“Low risk”
Goal: Monitor & manage
Goal: Identify & intervene
Goal: Engage & empower

8. Geography

9. Other Characteristics
Age or other demographic feature
Examples: Children, elders
Common need or concern
Examples: People who are homeless or without food
Common experience
Examples: Veterans, employees
Some combination of considerations
Example: Adults with behavioral health needs

10. Population health is about
improving the health & wellbeing of groups of people.

11. Together, we decide what groups of people should be our priority.

12. And then build solutions through partnerships

13. “Every year, more than 11 million people move through America's 3,100 local jails, many on low-level, non-violent misdemeanors, costing local governments approximately $22 billion a year. ln local jails, 64 percent of people suffer from mental illness, 68 percent have a substance abuse disorder, and 44 percent suffer from chronic health problems.
Communities across the country have recognized that a relatively small number of these highly-vulnerable people cycle repeatedly not just through local jails, but also hospital emergency rooms, shelters, and other public systems, receiving fragmented and uncoordinated care at great cost to American taxpayers, with poor outcomes.”
June 30, 2016
The White House
Office of the Press Secretary
Fact Sheet for the Data-Driven Justice Initiative

14. “Every year, more than 11 million people move through America's 3,100 local jails, many on low-level, non-violent misdemeanors, costing local governments approximately $22 billion a year. ln local jails, 64 percent of people suffer from mental illness, 68 percent have a substance abuse disorder, and 44 percent suffer from chronic health problems.
Communities across the country have recognized that a relatively small number of these highly-vulnerable people cycle repeatedly not just through local jails, but also hospital emergency rooms, shelters, and other public systems, receiving fragmented and uncoordinated care at great cost to American taxpayers, with poor outcomes.”
June 30, 2016
The White House
Office of the Press Secretary
Fact Sheet for the Data-Driven Justice Initiative

15. AHCCCS Targeted Investments Program

16. “Social Determinants of Health”
Source: CHCS Brief, Dec 2016; adapted from McGinnis et al, Health Affairs 2002: 21(2)

17. Comprehensive Care Management
AHCCCS Care Coordination Development Work Session
Resource Network
Community Medic Program
Child Care Services
Transportation
Food /Meal Assistance
Financial Assistance
Agencies
Needs
Spiritual Supports
Assistance with Daily Needs
Permanent Supportive Housing
School-based svcs
Social Service Agencies
Physical therapy & rehab
Patient & Care Team
Shelters & Transitional Housing
Supports for Life Instabilities
Behavioral Health Services
Behavioral Health Treatment
Family Supports
Case Management
Crisis Response Services
Substance Abuse Care
Palliative Care
Peer supports
Collaborative Care Processes
Transition Clinics
Home Health Services
Specialty Care
Telehealth & eHealth
Pharmacy services
Community Health Workers
Primary Care & Medical Homes
Post-Acute Care
Adapted from model developed with the Care Management Team at Northern Arizona Healthcare

18. Outcomes Hospital readmissions Avoidable ED visits Ambulatory visits
Satisfaction
Stable housing
Risk screening
Clinical condition outcomes
Cost
Integrated care plan development
Linkage to community supports
Health insurance status

19. Outcomes Repeat incarceration Avoidable ED visits Ambulatory visits
Satisfaction
Stable housing
Risk screening
Clinical condition outcomes
Cost
Integrated care plan development
Linkage to community supports
Health insurance status

20. Interdisciplinary collaboration works.

21. Two Expert Perspectives

22. Thank you