The term “population health” began emerging in U.S. health care circles around March 2003 when David Kindig and Greg Stoddart co-authored an article in the American Journal of Public HealthCare Management entitled “What is Population Health?”  In the article, the authors provide a working definition for population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”  The authors go on to stress the importance of considering the multiple determinants of health within populations that contribute to health status, such as: medical care, public health interventions, social environment (income, education, employment, social support, culture) physical environment (urban design, clean air and water), genetics, as well as individual health related behaviors.  

In early 2010, CMS developed a Quality Improvement Strategy for the Medicare Advantage (MA) and Prescription Drug Plan (PDP) Programs based on the Institute of Medicine (IOM) report from 2001 and the Triple Aim.  The Triple Aim concept is a quality improvement approach developed by Don Berwick, M.D., Institute for Healthcare Improvement (IHI) President Emeritus and former Administrator of the Centers for Medicare & Medicaid Services (CMS).  The Triple Aim strives to drive healthcare organizations and providers to implement programs that improve the patient care experience, improve the health of patient populations, and reduce the per capita cost of health care.  CMS’s Quality Improvement Strategy was expanded in 2011 to reflect the Department of Health and Human Services’ (HHS) National Strategy for Quality Improvement in Health Care, referred to as the National Quality Strategy (NQS), and the National Prevention Strategy (NPS), both of which were developed in accordance with the Affordable Care Act (ACA). CMS released the final MA and PDB Quality Strategy in June 2012.  The Quality Strategy outlines, in part, CMS’ framework for promoting quality improvements in care and services for all MA beneficiaries enrolled in MA and PDP plans. The Quality Strategy emphasizes the important roles of care coordination and evidence-based protocols in improving the health of MA beneficiaries. Chisara N. Asomugha, MD, MSPH, FAAP Director, Division of Population Health Incentives and Infrastructure, with the Innovation Center at CMS has outlined CMS’s vision of population health which includes, but is not limited to, the following:

• Alignment with the CMS Quality Strategy and National Prevention Strategy
• Incorporation of population health tools and concepts into emerging models, programs and initiatives
• Development of new care management strategies and models that incorporate social determinants of health and clinical care
• Establishment of stronger linkages between clinical care and community services

There is growing recognition in the health care community, as evidenced by the evolving strategies of quality improvement and regulatory leaders, that social and economic factors play a critical role in shaping an individual’s ability to engage in healthy behaviors. The Population Health Alliance indicates global research has revealed that the health care an individual receives predicts “only 10 – 20% of health outcomes, 20 – 30% from genetics, while 50 – 60% are based on individual health behaviors related to social and environmental factors.”  Addressing social determinants of health is not only important for improving overall health of a given individual, but also for advancing the health outcomes of populations.   

To achieve improvements in population health by identifying and addressing social determinants of health, industry experts, including Gorman Health Group, agree on some guiding principles to drive improved health outcomes, including:

• Assessment Tools:   Understanding a person’s social needs can be challenging, especially if there are barriers to obtaining information, such as language, health literacy and even fear related to sharing deeply personal information. Currently, several state Medicaid programs require their contracted MCOs to screen for social determinants of health and then refer patients to the resources.  It’s best to use an assessment tool that is short and simple, no more than twelve questions, written at a fifth grade or lower reading level, and available in multiple languages as applicable. Use of automated tools with embedded logic to identify potential referrals and resource supports are not widely in use, but are considered a best practice. 
  
• Data Sharing and Coordination:  It’s critical to utilize health management systems with capabilities to securely track, share and integrate data across multiple stakeholders; as well as manage referrals to needed resources.  Technology plays a major role in fueling collaboration among individuals and their health care team and is essential to improving health outcomes and reducing health costs. On March 4, 2019, CMS published a wide-ranging proposed rule (“Proposed Rule”) with the intent to “move the health care ecosystem in the direction of interoperability” in alignment with the objectives set out in the 21st Century Cures Act and Executive Order 13813. CMS believes patients should have the “ability to move from health plan to health plan, provider to provider, and have both their clinical and administrative information travel with them throughout their journey.”

• Aligning Resources:  Use of community resources is a widely accepted practice to support social and behavioral needs. Many hospitals and managed care organizations create detailed databases of community resources, including resources that are public health-funded, such as: medical and behavioral health homes, community clinics, care managers or care navigators, aging and disability resource centers, area agencies on aging, adult day health, housing authority or housing with service providers, food banks, pharmacies offering medication therapy management, as well as pharmacies that deliver medications to beside or home. 

New resources/roles are appearing in primary care practices to support patient needs. Physician groups are utilizing care managers/navigators to provide critical support around care coordination and patient care management interventions. In addition to case and disease managers, managed care organizations are also employing Social Workers to support care management strategies. Social workers are trained to understand the comprehensive landscape of available social services in a community and assist patients with accessing these resources.    

Lastly, many organizations including hospitals, physician group practices and managed care organizations have embraced the concept of an inter-disciplinary care team (ICT) approach to support patient needs. This involves utilizing professionals from different disciplines to work together to share expertise, knowledge, and skills; and work collaboratively with the patient. Generally speaking, the goals of the ICT are to manage care and services, to avoid fragmentation, ensure access to appropriate and person-centered care, and provide a team approach to address clinical, socioeconomic, and behavioral needs. To promote the effectiveness of the ICT, it’s important that team members understand their responsibilities and promote role interdependence while respecting the patient’s preferences and autonomy.   

The U.S. chronic illness burden continues to increase, and the effect is felt much more strongly among the elderly, minority and low income populations. Opportunities abound for effective care management strategies to support and advance population health initiatives, particularly as it relates to having a positive impact on social determinants of health.  Gorman Health Group has the expertise and resources to assist organizations with effective care management strategies to support population health goals.