Population Health · Creating a Culture of Wellness by Nash, David B. -- Read -- Imperial Library of Trantor

Index

Cover Title Page Copyright Page Brief Contents Contents Foreword Preface The Optimistic Future for HealthCare: Population Health from Philosophy to Practice Contributors List Chapter 1 The Population Health Promise

Introduction The Current State of Population Health Population Health Defined Foundations of Population Health

The Care Continuum The Science The Effect on and Response by the Marketplace The Politics

Frameworks for Innovation

Healthy People 2020 Triple Aim Practical National Priorities and Goals—The CDC 6/18 Initiative

Preventive Strategies and Pillars of Population Health

Preventive Strategies The Four Pillars Care Management Quality and Safety Public Health and Health Policy

Conclusion

Chapter 2 Epidemiology

Introduction Leading Causes of Death in the United States

Determinants of Causes of Death and Disease in the United States Distributions and Health Disparities

What Is Epidemiology and Why Is It Important?

Population Medicine “What Is Upon the People” Objectives of Epidemiology

History of Epidemiology

John Snow and Cholera in London Epidemiologic Transition

Modes of Practice of Epidemiology

Quantification Sources of Epidemiologic Data

Epidemiology in Practice

Descriptive Epidemiology: Quantifying Disease among Populations Rates Epidemic

Analytic Epidemiology: Searching for the Causes of Disease among Populations

Experimental Studies Observational Studies Epidemiology and Population Health Integrating Social Determinants of Health in EMR

The Future of Epidemiology in Population Health

Chapter 3 On the Path to Health Equity

Introduction Health Equity Racism, Trust, Stigma, and Bias

Cultural Competence It Will Take the Entire Team and Some New Players

Conclusion

Chapter 4 Structure, Systems, and Stakeholders

Introduction

The Preindustrial Era (Mid-18th to Late 19th Century) The Industrial Era (Late 19th to Late 20th Century) The Corporate Era (Late 20th Century to the 21st Century)

The Evolution of Health Insurance

Commercial and Employer-Sponsored Insurance Medicare Medicaid Veterans Affairs and TRICARE Children’s Health Insurance Program and American Indian and Alaska Native High-Deductible Health Plans (HDHP)

Healthcare Delivery Systems

Healthcare Providers Physicians Nursing Advanced Practitioners Pharmacists Community Health Workers Types of Delivery Systems Managed Care Organizations Accountable Care Organizations Veterans Administration Federally Qualified Health Centers Telehealth

Stakeholders

Patients/Consumers Providers Payers Pharmaceutical Industry

Conclusion

Chapter 5 Reimbursement Models to Support Value-Based Care

Introduction Definition of Value

Economic Concepts Health Insurance and the Elements of the Fee-For-Service, Value-Based Care Continuum Evaluating Value-Based Care Reimbursement Models Stakeholder Perspectives on Value-Based Care Models

Conclusion

Chapter 6 Population Health Data and Analytics

Population Health and the Importance of Data Clinical Data: Electronic Health Records Interoperability: EHRs Exchanging Data

System-to-System Interoperability via HL7-Based Interfaces Transitions of Care Among Healthcare Organizations— C-CDA-Based Interoperability Application Interoperability Using FHIR

Health Information Exchanges Patient-Generated Data Payment Models and How They Depend on IT Systems Financial and Claims Data

Claims Payment and Reimbursement Capitation Attribution Utilization Approximation by Counting Encounters and Length of Stay

Social Determinants of Health Data Aggregation Data Quality Data Governance Risk Stratification Analysis and Reporting Artificial Intelligence and Machine Learning in Population Health Conclusion

Chapter 7 Developing the Workforce to Enhance Population Health

Introduction A Focus on Population Health

Social Determinants Drive Population Health Collaboration Is Required Across the Health Ecosystem

Population Health Strategy

Developing Workforce Support for Population Health Strategy

Creating a Workforce Development Strategy and Plan

Defining the Need: Identify Critical Roles Building the Workforce Development Plan: Another Word About Culture

Conclusion Workforce Development: An Executive Leadership Example

Introducing Beta Health System Supporting the Culture That Supports the Strategy Identifying Critical Executive Roles, Competencies, and Competency Gaps The Executive Development Plan Aligning Culture

Chapter 8 Health Promotion and Health Behavior

Introduction The Role of Behavior in Morbidity and Mortality

How Theory Informs Health Promotion and Disease Prevention Designing Theoretically Grounded Interventions (PRECEDE-PROCEED Model) Major Theories in Public Health and Interventions in Practice Evaluating Theory-Based Programs in Public Health Practice

Conclusion

Chapter 9 Consumer Engagement and Technology

Introduction Sphere 1: Personal Technologies

Wearables and the Internet of Things (IOT) Nudges and Social Comparisons

Sphere 2: Social Media and Trust

“Influencers” and the Growing Wellness Industry

Sphere 3: Retail and Business The Case of Caregiving Conclusion

Chapter 10 Accountability for Outcomes

Purposes of Measurement: The “Why”

Measurement for Improvement Measurement for Accountability Measurement for Research

Accountability for Outcomes: The “How” Outcomes Measurement: The “What”

Triple Aim Measurement Framework Triple Aim Measurement Guide The Quadruple Aim

Conclusion

Chapter 11 Changing Organizational Culture

Introduction

Failure of Ideas Failures of Will Failure of Execution Strategies for Success

Framework 1: Switch

Switch Framework Case Study 1: Adopting Systemwide Change Switch Framework Case Study 2: Ensuring End-of-Life and Healthcare Proxy Discussions

Framework 2: Psychology of Change Framework 3: The Kotter Eight-Step Change Model

Eight-Step Framework Case Study 1: System Transformation Eight-Step Framework Case Study 2: 100 Million Healthier Lives

Takeaways for Change Leaders

Chapter 12 Coordinated Care Delivery Models

Introduction

Total Cost of Care APM Example: Accountable Care Organizations Primary Care APM Example: Comprehensive Primary Care (CPC) Program Condition-Specific APM Example: Oncology Care Model and the Patient-Centered Specialty Practice Condition-Specific APM Example: Bundled Payment for Care Improvement

Care Coordination Operations in Ambulatory Care

Interprofessional Collaboration and Practice Transformation Coordinating Care Transitions How to Manage Change When Providers Are Still Primarily Working on Volume

Conclusion

Chapter 13 Policy and Advocacy

Introduction The Policymaking Process

Considerations in Policymaking

Key Players in Federal Policymaking

U.S. Congress Legislative Branch Agencies U.S. Department of Health and Human Services

Experimentation Before CMMI

Paradigm Shift: The ACA

Recent Developments Advocacy

What Is Lobbying? Who Lobbies?

NashvilleHealth: A Vignette on a Coalition

Evaluating NashvilleHealth Interventions Utilizing Healthy People 2020 Goals Data

Conclusion

Chapter 14 Building Cultures of Health and Wellness Within Organizations

Introduction What Is a Culture of Health and Wellness?

Communication Encouragement and Engagement Access Evidence-Based Practice Supportive Environment Evaluation and Improvement

What Is a Benchmark Organization? How Does an Organization Get Started?

Establish a Vision for Health Engage Senior Leadership and Align Management Develop Supporting Workplace Environmental Changes and Implement Workplace Policies Construct a Comprehensive Integrated Data Warehouse Utilize Value-Based Benefit Design and Behavioral Economics Implement Broad Population Health Activities

Aligning Key Constituencies Comparison to Benchmarks A Market-Based Solution to the Healthcare Crisis Justification and Business Case: The Connection Between Health and Wealth Conclusion

Appendix I Case Study: Michigan Primary Care Transformation Project (MiPCT) and the Role of Multipayer Primary Care Initiatives in Achieving Population Health Appendix II Case Study: Assessing Organizational Readiness for Population Health Appendix III Case Study: The Power of Community in Population Health: PowerUp for Kids Glossary Index

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