Population Health

Population health is an approach to care that uses information on a group of patients within a practice—or group or practices—to improve the care and clinical outcomes for those patients. Population health shifts the focus from caring for patients as they come into the office one after the other, to proactively managing a practice's patient panel using emerging technology and available evidence.  

Population health also involves having a better understanding about the community in which patients reside; factors that might increase health risks, factors that might be protective, and the range of community resources that exist for patients and families and how to access them.

Tips for implementing population health interventions in the pediatric practice setting are as follows:

Use an electronic system that will record patient information as structured (searchable) data and has the ability to pull reports based on this data

Conduct comprehensive health assessments for all patients and update this information during each visit to ensure the data is current

A comprehensive health assessment is a systematic collection and analysis of information related to a patient's health. Most practices determine the information to include based on their patient population. To improve practice workflow, the health assessment tool should be integrated into the practice's EHR system in a seamless way. Practices can use the time prior to appointments or during the clinical intake (with assistance from the medical assistant or scribe) to have patients and families review and update this information.

Practices should also capture the following information:

Collect, understand, and regularly update the patient's family, social and cultural characteristics. Examples of these characteristics can include family/household structure, support systems, household/environmental risk factors, and patient/family concerns.
Collect, understand and regularly update the communication needs of the patient and family. Your practice should identify and document whether the patient or family has specific communication requirements due to limited English proficiency (LEP), or hearing, vision, or cognition issues.

Resource:

Bright Futures Tool and Resource Kit: Includes pre-visit questionnaires and visit-specific supplemental questionnaires designed to capture relevant patient information and clinical data. 

Become familiar with the health-related statistics, rankings, environmental characteristics, and available resources of your community

There is a vast array of data from the state/local health department, US Census Bureau, the CDC, and through other national surveys that can provide you with a better understanding about the health of your neighborhood and community. Understanding this information will help your practice to identify potential topics to address with patients and families during health supervision visits, and for educational interventions within your practice.

Resource:

Creating a Health Profile of Your Neighborhood: A How-To Guide. This document provides practical guidance on where to look to obtain health-related data specific to your community. 

Examine both practice and community data and identify a metric your practice would like to improve, or a topic your practice would like to address

Examining how you’re currently performing on specific measures might help you decide which areas to target first. Select 1 or 2 specific things to start with. Some ideas follow:

Identify patients who are behind on well-child visits based on the Bright Futures Guidelines for Health Supervision and the AAP Periodicity Schedule.
Identify patients who are behind on immunizations based on the ACIP/AAP recommended Immunization Schedule.  
Does your practice have a high incidence of patients with a specific chronic illness? Are these patients up to date on disease-specific care or is there a need for more education?
Consider a specific quality improvement activity through the AAP.
The Community Guide is designed to help identify and select evidence based interventions to improve health and prevent disease in the community.

Plan the population health intervention and identify (via the EHR or registry) the patients to target

Your EHR can be used to develop a listing of patients to be targeted for the intervention, along with their contact information. If you are unsure about whether your EHR system has this capability, it is best to talk to your EHR vendor. Alternatively, a registry can be used to pull this information.

Consider obtaining input from youth and families in your practice about the planned intervention and messaging preferences, as youth/families offer unique perspectives about the messages that resonate the most with them.  

Implement the population health intervention

Contact your targeted list of patients and explain the intervention to them. If your intervention relates to reminding specific patients/families about needed services, they should be contacted to schedule an appointment. A phone, email and text script should be developed for your staff to follow. If your intervention will be implemented as patients and families come in for office visits, consider utilizing a checklist or EHR alert so that patients can be identified during the pre-visit record review process or upon arrival for an office visit.

Evaluate the intervention and measure change

If a reminder system was used, what was the success rate in reaching the patient (eg, what percentage of patients/families opened the message)? How effective was the reminder (eg, what percentage of the patients received the service)? Assess the data to determine opportunities to improve, and periodically examine your practice's data to determine whether to modify and/or repeat the intervention.

Last Updated

08/09/2021

Source

American Academy of Pediatrics