1. POPULATION HEALTH: BEYOND MANAGING HIGH UTILIZERS David B. Coultas, MD VA Portland Health Care System Professor, OHSU

2. Knowing the health outcomes of group(s) of individuals, including the distribution of outcomes and their determinants. Using proactive, evidence-based, cost- effective population-level interventions to reduce variation/disparities in outcomes and add value to health system and community. DEFINITION: POPULATION HEALTH

3. COUNTY HEALTH RANKING MODEL POLICIES & PROGRAMS HEALTH FACTORS HEALTH OUTCOMES Physical Environment (10%) Built environment Environmental quality Social & Economic (40%) Education Social support Employment Income Safety Health Behaviors (30%) Tobacco Diet & Exercise Alcohol Sexual activity Clinical Care (20%) Access Quality Morbidity-QOL (50%) Mortality (50%)

4. Review barriers to improving population health. Describe strategies beyond targeting high utilization for improving population health. OBJECTIVES

5. There is wide cultural variation in beliefs about health and disease, which in-turn influences expectations and behaviors concerning health care. These variations in beliefs, expectations, and behaviors makes improving population health very complex. CULTURE OF HEALTH CARE

6. Focus on rescue care High waste Low health literacy Paternalistic Poor advanced care planning Focus on 1 o and 2 o prevention (e.g., social determinants) Low waste High health literacy Shared decision-making Informed advanced care planning HEALTH CARE CULTURE Current StateFuture State

7. Non-health care social service spending in US 0.9 to 1 vs. 2.0 to 1 in other developed countries $10/person/year in evidenced-based community interventions to increase physical activity, improve nutrition, and prevent smoking could save the US more than $16 billion/year within 5 years. ROI: PUBLIC HEALTH VS. HEALTH CARE www.healthyamericas.org/reports/prevention08/Prevention08.pdf Bradley et al. BMJ Qual Saf 2011;20:826-31

8. $476 (~18%) - $992 (~37%) billion of spending on health care in US is wasted: – Failure of care delivery – Failure of care coordination – Overtreatment – Administrative complexity – Overpricing – Fraud and abuse Berwick, Hackbarth. JAMA 2012;307:1513-16. WASTE IN US HEALTH CARE SYSTEM

9. CHRONIC CARE MODEL

10. Limited health literacy Lack of empathy Communication discordance/errors – Failure to communicate – Biased communication Limited informed/shared decision-making GAPS IN COMMUNICATION

11. US ADULT HEALTH LITERACY, 2003 DHHS. www.health.gov/communication/literacy/issuebrief / Proficient 12%

12. PREVALENCE OF LIMITED HEALTH LITERACY Berkman et al. Ann Intern Med 2011;155:97 80 million with limited health literacy, highest among: – Elderly – Minority – Poor persons – < High school education

13. COMMUNICATION & SELF-EFFICACY Knowledge OutcomesBeliefs Self-management behaviors Self-efficacy Skills

14. SELF-MANAGEMENT

15. HEALTH LITERACY & ADVANCED CARE PLANNING Health Literacy & ACP Knowledge gaps Death Uncertainty Prognosis Options Futile Care Self-efficacy Fear

16. CHRONIC CARE MODEL

17. Reduce waste Improve health literacy Promote informed/shared decision-making Proactive advanced care planning IMPROVING POPULATION HEALTH

18. QUESTIONS?

19. VALUE VALUE = OUTCOMES/COSTS