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POPULATION HEALTH: BEYOND MANAGING HIGH UTILIZERS
David B. Coultas, MDVA Portland Health Care System
Professor, OHSU
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• 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
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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%)
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• Review barriers to improving population health.
• Describe strategies beyond targeting high utilization for improving population health.
OBJECTIVES
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• 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
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• Focus on rescue care
• High waste• Low health literacy• Paternalistic• Poor advanced care
planning
• Focus on 1o and 2o prevention (e.g., social determinants)
• Low waste• High health literacy• Shared decision-making• Informed advanced care
planning
HEALTH CARE CULTURE
Current State Future State
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• 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
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• $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
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CHRONIC CARE MODEL
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• Limited health literacy• Lack of empathy• Communication discordance/errors
– Failure to communicate– Biased communication
• Limited informed/shared decision-making
GAPS IN COMMUNICATION
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US ADULT HEALTH LITERACY, 2003
DHHS. www.health.gov/communication/literacy/issuebrief/
Proficient 12%
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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
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COMMUNICATION & SELF-EFFICACY
Communication
Knowledge
OutcomesBeliefs Self-managementbehaviors
Self-efficacy
Skills
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SELF-MANAGEMENT
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HEALTH LITERACY & ADVANCED CARE PLANNING
Health Literacy
&ACP
Knowledge gaps
DeathUncertaintyPrognosisOptions
FutileCare
Self-efficacy
Fear
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CHRONIC CARE MODEL
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• Reduce waste• Improve health literacy• Promote informed/shared decision-making• Proactive advanced care planning
IMPROVING POPULATION HEALTH
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QUESTIONS?
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VALUE
VALUE = OUTCOMES/COSTS