Population Health Management

Editor-in-Chief: David B. Nash, MD, MBA

ISSN: 1942-7891 | Online ISSN: 1942-7905 | Published Bimonthly | Current Volume: 25

Impact Factor: 2.290* *2021 Journal Citation Reports™ (Clarivate, 2022)

CiteScore™: 3.3

The only peer-reviewed journal dedicated to the rapidly evolving field of population health, covering the interplay of health outcomes, social determinants of health, and the policies and interventions that move our systems from acute care to health care.

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Featured Content

Press

Health Care Access Improves with State-Level Medicaid Expansion

Food Insecurity and Hospital Visits - Is There a Link?

Having access to adequate and appropriate food is a major population health issue. This study investigated food insecurity in patients with high rates of inpatient hospitalization (“super-utilizers”). Forty adults with =3 hospital inpatient admissions within a 12-month period were interviewed in an urban hospital in Philadelphia, Pennsylvania, between March 2015 and May 2015. Inpatient admission history was obtained from hospital billing data. The majority had =5 hospitalizations in the past 12 months and =6 chronic conditions. Using the USDA definition of food insecurity, 30% (95% CI, 17% to 47%) were food insecure and 25% (95% CI, 13% to 41%) were marginally food secure. Forty percent responded that, in the past 30 days, they worried that their food would run out; 35% that their food would not last; 17.5% that they did not eat for a full day; and 10% that they were hungry but did not eat some or all of the time. Additionally, 75% were unable to shop for food on their own and 58% were unable to prepare their own food. More than half reported using food pantries or other community food resources. The impact of unmet food needs on hospital super-utilization warrants further investigation. Interventions that educate and connect patients with unmet food needs to community resources can help engage patients in their own health and well-being. Communication with patients about whether they have enough nutritionally appropriate food for their health conditions is an important starting point.

Expert Panel Urges New Approaches to Curtail U.S. Opioid Epidemic

The American Opioid Epidemic: Population Health Implications and Potential Solutions. Report from the National Stakeholder Panel Janice L. Clarke, RN, Alexis Skoufalos, EdD, and Richard Scranton, MD, MPH Editorial: David B. Nash, MD, MBA S-1 Introduction S-1 The Evolution of Opioid Use in the United States S-2 Unintended Consequences of Postsurgical Pain Management S-2 Pivotal Role of Postsurgical Prescribing Practices S-3

• Population health and societal implications S-4

The Case for Multimodal Pain Management for Surgical Patients S-4 Optimizing Health Outcomes S-4

• Emerging profile of opioids: pros and cons S-5
• Planning for perioperative pain S-5
• Minimizing risk of postsurgical overuse and misuse of opioids S-5

Optimizing Economic Outcomes by Managing Pain Differently S-6 Expert Panel Insights S-7 Conclusion S-7

Can Health Coaches Improve Care of Insured Patients with Chronic Diseases?

Health coach programs using low-cost unlicensed providers have largely targeted uninsured or underserved populations, raising questions about uptake and effectiveness for insured patients. This observational study evaluated the referral process, uptake, and effectiveness of a health coach program for patients with diabetes and/or hypertension at a multispecialty clinic. Data included appointment observations; interviews with patients, physicians, and health coaches; patient and physician characteristics; and measures of utilization and clinical outcomes. Out of 1313 eligible patients, 308 (23.5%) were referred over a 12-month period and 169 (54.9%) had at least 1 health coach appointment. Although the health coach program did not change patients" biometrics, physicians and patients reported improved care processes and reduced physician workload. Barriers to enrollment included variability in physician referral practices, patient willingness, and scheduling difficulties. Modifications to physician and health coach workflow are needed to determine the program"s true effectiveness.

Successful Model for Statewide Collaborative Initiative to Reduce Avoidable Hospital Readmissions

Increasing scrutiny of hospital readmission rates has spurred a wide variety of quality improvement initiatives. The Preventing Avoidable Readmissions Together (PART) initiative is a statewide quality improvement learning collaborative organized by stakeholder organizations in South Carolina. This descriptive report focused on initial interventions with hospitals. Eligible participants included all acute care hospitals plus home health organizations, nursing facilities, hospices, and other health care organizations. Measures were degree of statewide participation, curricular engagement, adoption of evidence-based improvement strategies, and readmission rate changes. Fifty-nine of 64 (92%) acute care hospitals and 9 of 10 (90%) hospital systems participated in collaborative events. Curricular engagement included: webinars and coaching calls (49/59, 83%), statewide in-person meetings (35/59, 59%), regional in-person meetings (44/59, 75%), and individualized consultations (46/59, 78%). Among 34 (58%) participating hospitals completing a survey at the completion of Year 1, respondents indicated complete implementation of multidisciplinary rounding (58%), post-discharge telephone calls (58%), and teach-back (32%), and implementation in process of high-quality transition records (52%), improved discharge summaries (45%), and timely follow-up appointments (39%). A higher proportion of hospitals had significant decreases (=10% relative change) in all-cause readmission rates for acute myocardial infarction (55.6% vs. 30.4%, P=0.01), heart failure (54.2% vs. 31.7%, P=0.09), and chronic obstructive pulmonary disease (41.7% vs. 33.3%, P=0.83) between 2011–2013 compared to earlier (2009–2011) trends. Focus on reducing readmissions is driving numerous, sometimes competing, quality improvement initiatives. PART successfully engaged the majority of acute care facilities in one state to harmonize and accelerate adoption of evidence-based care transitions strategies. (Population Health Management 2016;19:4–10)

The views, opinions, findings, conclusions and recommendations set forth in any Journal article are solely those of the authors of those articles and do not necessarily reflect the views, policy or position of the Journal, its Publisher, its editorial staff or any affiliated Societies and should not be attributed to any of them.