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Table of Contents


	About the Authors	xvii
	Foreword	xxiii
	Preface	xxvii
	Contributors	xxxi
	The Population Health Mandate Valerie P. Pracilio, MPH, JoAnne Reifsnyder, PhD, ACHPN, David B. Nash, MD, MBA, and Raymond J. Fabius, MD	xxxv
SECTION I	PROVIDING POPULATION HEALTH
Chapter 1	The Spectrum of Care Jaan Sidorov, MD, MHSA, and Martha Romney, MS, JD, MPH	3
	Introduction	4
	What is �Population Health� and Why is this Approach Necessary?	4
	Attributes of the Population Health Paradigm	6
	Components of the Population Health Paradigm	7
	Health Promotion	7
	Prevention	7
	Screening	9
	Behavior Change (Health Management)	9
	Patient Self-Care	10
	Patient-Centered Medical Home	10
	Chronic Care Management and Disease Management	11
	Eliminating Health Disparities	12
	Cultural Competency	13
	National Initiatives Addressing Population Health Needs	14
	The National Priorities Partnership	14
	Healthy People Initiatives	15
	State-Based Initiatives	15
	Challenges in Implementing a Population Health Approach	16
	Clinical	16
	Policy	16
	Business	16
	Conclusions	17
	Study and Discussion Questions	17
	Suggested Readings and Web Sites	17
	Readings	17
	Web Sites	18
	References	19
Chapter 2	Behavior Change James O. Prochaska, PhD, and Janice M. Prochaska, PhD	23
	Introduction	24
	The Transtheoretical Model of Behavior Change	25
	Core Constructs	25
	Stages of Change	26
	Processes of Change	27
	Decisional Balance	29
	Self-Efficacy	29
	Temptation	30
	Critical Assumptions	30
	Empirical Support and Challenges	31
	Stage Distribution	31
	Pros and Cons Structure Across 12 Behaviors	31
	Integration of Pros and Cons and Stages of Change Across 12 Health Behaviors	31
	Strong and Weak Principles of Progress	32
	Processes of Change Across Behaviors	32
	Relationship Between Stages and Processes of Change	33
	Applied Studies	33
	Multiple Behavior Change Programs: Increasing Impact	34
	Future Research	36
	Future Practice	37
	Conclusions	38
	Study and Discussion Questions	38
	Suggested Readings and Web Sites	38
	Readings	38
	Web Sites	39
	References	39
Chapter 3	Health System Navigation: The Role of Health Advocacy and Assistance Programs Abbie Leibowitz, MD, FAAP	43
	Introduction	45
	The Emergence of Health Advocacy and Assistance Programs	46
	Goals of Advocacy and Assistance Programs	47
	The Constituents	47
	The Employers� Perspective	47
	The Consumer�s Perspective�Consumer-Driven Health Care	50
	The Physician�s Perspective	51
	The Perspective of Health Plans and Administrators	51
	Health Advocacy as an Independent Service	52
	A Matter of Trust	52
	What Help do Consumers Need?	53
	Access to Care	55
	Making Connections Across the Spectrum of Care	57
	Coordinating Care Across Benefits Programs	58
	Changing Consumer Behavior	58
	Conclusions	59
	Study and Discussion Questions	59
	Suggested Readings and Web Sites	60
	Readings	60
	Web Sites	60
	References	60
Chapter 4	Continuity of Care JoAnne Reifsnyder, PhD, ACHPN, and Theresa P. Yeo, PhD, MPH, MSN, CRNP	63
	Introduction	65
	Risk Factors for Chronic Disease	66
	Overview of Chronic Conditions	66
	Diabetes	67
	Cancer	67
	Cardiovascular Disease	69
	Asthma	70
	Mental Health Disorders	71
	Impact of Chronic Conditions	71
	Care Delivery Variation	71
	Chronic Care Management	72
	Self-Management of Chronic Conditions	73
	Chronic Disease Self-Management Program	73
	The Wagner Chronic Care Model	74
	Publicly Funded Home- and Community-Based Services	74
	State Home- and Community-Based Models	74
	Program of All-Inclusive Cafe for the Elderly	75
	Physician Practice-Centered Models	76
	Patient-Centered Medical Home	76
	Guided Care	78
	Community-Based, Fee-for-Service Model: Geriatric Care Management	79
	Palliative and End-of-Life Care	80
	Workforce Needs for an Aging Society With Increasing Chronic Illness	82
	Conclusions	83
	Study and Discussion Questions	83
	Suggested Readings and Web Sites	84
	Readings	84
	Web Sites	84
	References	84
Chapter 5	Population Health Quality and Safety Susan DesHarnais, PhD, MPH, and Valerie P. Pracilio, MPH	89
	Introduction	90
	Advances in Quality and Safety	91
	What has Worked	93
	Reducing Fragmentation	94
	A Framework for Achieving Health and Wellness	94
	Quality and Safety Measurement: The Consumer�s Perspective	94
	A Consumer�s View of Quality and Safety	95
	An Institution�s View of Quality and Safety	96
	Creating an Epidemic of Health and Wellness	97
	Epidemlological Factors	97
	Achieving Health and Wellness	98
	Conclusions	102
	Study and Discussion Questions	102
	Suggested Readings and Web Sites	102
	Readings	102
	Web Sites	103
	References	103
Chapter 6	Risk Management and Law Henry C. Fader, Esq.	105
	Introduction	106
	The Role of Law	107
	Patient Advocacy	109
	Provider Advocacy	110
	Advocating for Population Health and Wellness	113
	Tax Status	114
	Employer-Based Health Insurance	114
	Conclusions	116
	Study and Discussion Questions	116
	Suggested Readings and Web Sites	116
	Readings	116
	Web Sites	117
	References	117
SECTION II	THE BUSINESS OF HEALTH
Chapter 7	Making the Case for Population Health Management: The Business Value of Better Health Ronald R. Loeppke, MD, MPH, FACOEM, FACPM	121
	Introduction	123
	The Business Case for Good Health	124
	Relationship Between Health and Productivity	124
	Impact of Productivity on Business	125
	Workforce Issues	127
	Access to Care and Disparities	128
	Key Players in Population Health Management	129
	The Purchaser�s Role	129
	The Health Plan�s Role	130
	The Healthcare Consultant�s Role	130
	The Specialty Vendor�s Role	131
	The Value of Population Health Management Strategies	132
	Making the Business Case	132
	Conclusions	134
	Study and Discussion Questions	134
	Suggested Readings and Web Sites	134
	Readings	134
	Web Sites	135
	References	135
Chapter 8	The Business Case for Cultural Change: From Individuals to Communities Mario Moussa, PhD, MBA, and Jennifer Tomasik, MS	137
	Introduction	138
	What is the Cost?	138
	Populations vs. Patients	139
	Preventive vs. Reactive	142
	Chronic Conditions vs. Acute Conditions	144
	Integrated Healthcare Teams vs. Physicians	145
	Communities vs. Individuals	145
	Conclusions	148
	Study and Discussion Questions	149
	Suggested Readings and Web Sites	149
	Readings	149
	Web Sites	149
	References	149
Chapter 9	Information Technology John K Cuddeback, MD, PhD, and Donald W. Fisher, PhD	153
	Introduction	154
	From Paper Medical Records to the EHR	155
	Inferential Gap	156
	Structured Data	156
	Patient- and Population-Level Clinical Decision Support	158
	Systems and Data Sources Other Than the EHR	159
	Administrative Systems	159
	System Architecture	160
	Claims Data	160
	Three Major Categories of Systems	163
	Transaction Systems	163
	Data Warehouses	165
	Disease Registries	165
	Creating Data Warehouses	166
	Mapping to Common Terminology	166
	Challenges in Creating Data Warehouses	170
	Public Health Informatics	171
	Practical Issues of EHR Implementation and Adoption	171
	Importance of Process Redesign and Cognitive Support	172
	Impact of Organizational Culture	173
	Incentives for E-Prescribing and �Meaningful Use� of EHRs	174
	Interoperability	174
	Privacy and Security	175
	Unintended Consequences	176
	Conclusions	176
	Study and Discussion Questions	177
	Suggested Readings and Web Sites	177
	Readings	177
	Web Sites	177
	References	178
Chapter 10	Decision Support Matthew C. Stiefel, MPA	181
	Introduction	182
	Three Main Purposes for Measurement in Population Health	182
	Measurement for Improvement	182
	The Model for Improvement	182
	Predictive Modeling	184
	Measurement for Accountability	188
	Measuring the Triple Aim	188
	Measuring Value and Efficiency	194
	Measurement for Research	195
	Conclusions	196
	Study and Discussion Questions	196
	Suggested Readings and Web Sites	196
	Readings	196
	Web Sites	197
	References	197
Chapter 11	Marketing and Communication: Methods for Reaching Populations William Haggett, EdD	199
	Introduction	200
	Engaging the Consumer	200
	Communication Strategies from Other Industries	201
	Why Communicate? What is the Communication Objective?	203
	Who is the Audience?	203
	What is the Message?	206
	How should You Communicate?	207
	What Works?	208
	Conclusions	209
	Study and Discussion Questions	210
	Suggested Readings and Web Sites	210
	Readings	210
	Web Sites	210
	References	210
SECTION III	MAKING POLICY TO ADVANCE POPULATION HEALTH
Chapter 12	Policy Implications for Population Health: Health Promotion and Wellness Tracey Moorhead, Jeanette C. May, PhD, MPH, and Kip MacArthur	215
	Introduction	216
	Key Players in Federal Policy Making	216
	Overview of Historical Demonstrations and Pilots	219
	State Case Studies in Disease Management	221
	Key Considerations in Policy Development	222
	Conclusions	224
	Study and Discussion Questions	226
	Suggested Readings and Web Sites	226
	Readings	226
	Web Sites	226
	References	227
Chapter 13	Ethical Dimensions of Population Health Francis Barchi, MS, MBE	229
	Introduction	230
	The Role of Ethics in Population Health	231
	Distinction Between Ethics in Population Health and Medical Ethics	231
	Moral Traditions and Theories	232
	Ethics in Population Health Practice	233
	Ethics in Population Health Research	234
	Allocation of Resources and Access	235
	Ethical Reflection and Decision Making in Population Health	236
	Conclusions	237
	Study and Discussion Questions	237
	Suggested Readings and Web Sites	237
	Readings	237
	Web Sites	238
	References	238
Chapter 14	Population Health in Action: Successful Models Paul Wallace, MD	241
	Introduction	242
	Why Focus on Chronic Medical Conditions?	242
	Care as Usual	243
	Disease Management and Practice Redesign	243
	Gauging Success�Assessment Framework	243
	Disease Management: A Model for Population Care	244
	Access and Spread	244
	Disease Management and Medicare	245
	Disease Management and Medicaid	247
	An Alternative Model: Clinical Practice Redesign	248
	The Chronic Care Model	248
	Practice Redesign and Integrated Delivery Systems	250
	PR in the Safety Net and Medicaid	250
	Conclusions	251
	Study and Discussion Questions	253
	Suggested Readings and Web Sites	253
	Readings	253
	Web Sites	254
	References	254
Chapter 15	Research and Development in Population Health R Dixon Thayer, Raymond J. Fabius, MD, and Sharon Frazee, PhD	257
	Introduction	258
	Effective Population Health Research	259
	State of the Art of Population Health Measurement	262
	The View from the Five Constituencies of Health Care	263
	Classes of Measures	263
	Techniques of Measurement	264
	Challenges to Successful Research	265
	Establishing Goals	266
	The Five Segments of Population Health Status	266
	Conclusions	267
	Study and Discussion Questions	268
	Suggested Readings and Web Sites	268
	Readings	268
	Web Sites	269
	References	269
Chapter 16	Population Health Education Brooke Salzman, MD, James D. Plumb, MD, MPH, and Richard Wender, MD	271
	Introduction	272
	The Need for Health Professional Education Reform	273
	The Need for a Population Health Approach to Health Professions Education	277
	Establishing a Framework in Population Health Education	279
	Examples of Developed Frameworks in Population Health and Strategies for Implementation	279
	Challenges and Barriers to Health Professions Education Reform and Implementing Curricula in Population Health	283
	Composition of the Population of Learners	283
	Characteristics of the Learning Environment	284
	Organization Structures and Sources of Support	286
	Recommendations	288
	Conclusions	289
	Study and Discussion Questions	289
	Suggested Readings and Web Sites	289
	Readings	289
	Web Sites	290
	References	290
Chapter 17	the Political Landscape in Relation to the Health and Wealth of Nations Alan Lyles, ScD, MPH, RPh	295
	Introduction	296
	Measuring and Comparing Population Health and Wealth	298
	Health	298
	Wealth	300
	Health and Disparities	301
	Federalism, Politics, and Population Health	304
	Interest Groups: The First Amendment, Pluralism, and Political Campaign Financing	306
	Public-Private Sector Arrangements in Health Care	307
	Conclusions	309
	Study and Discussion Questions	309
	Suggested Readings and Web Sites	310
	Readings	310
	Web Sites	310
	References	310
	The Future of Population Health: Moving Upstream Dee W. Edington, PhD, and Alyssa B. Schultz, PhD	313
	Introduction	314
	A Brief History of Population Health	316
	The Past: Prior to 1960	316
	The Past: Status of Population Health: 1960-2000	317
	The Past: Emergence of Population Health: 2000-2010	317
	Future Trends in Population Health Management	318
	The Future: Near- to Mid-Term: 2010-2014	318
	Natural Flow of a Population Among Health Risk Categories	319
	Natural Distribution of Healthcare Costs	320
	Information Technology	321
	Culture of Health	321
	The Future: Longer Term, 2015 and Beyond	323
	Precursors to Beyond Wellness (Totally Upstream)	323
	Conclusions	324
	Study and Discussion Questions	325
	Suggested Readings and Web Sites	325
	Readings	325
	Web Sites	325
	References	326
Appendix	Case Studies	329
Section I	Providing Population Health	329
	Behavior Change	329
	Risk Management and Law	331
Section II	The Business of Health	331
	Employee Health	331
	Decision Support	332
Section III	Making Policy to Advance Population Health	334
	Ethics and Population Health	334
	References	335
	Glossary	337
	Index	355