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Total Population Health

Rationale and Evidence Based Review of Approaches and Best Practices

December, 2014

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Summary Total population health has been defined as a health improvement model for residents within a geographical area. The MUSC total population health (TPH) population frame will be the tri-county area surrounding Charleston. TPH seeks to improve the health of the residents within the area. Health includes physical, emotional, social, lifestyle habits and socio-economic determinants beyond the mere absence of disease or acute illness. The inclusion of health equity or health disparities within the population as a consideration is a key aspect of TPH. An environmental scan of the literature and association publications was completed. Five common themes appeared to run throughout the available resources.

1. Patient Centric Focus 2. Information Technology Reformation 3. Workflow and Delivery System Reengineering 4. Recasting the Sphere of Interest and Influence 5. All-in, Creating Critical Mass to Sustain

TPH has been started to close multiple gaps that are present in the U.S. health care landscape. Studies and publications such as the Institute of Medicine, National Coalition for Quality Assurance, New England Journal of Medicine, and Journal of the American Medical Association have reported underperformance on a large scale.

91,000 Americans die prematurely for chronic conditions and heart disease annually Adherence to clinical guidelines, both patient and physician is 50/50 for most issues

o Physician encounter rates were higher at almost 75% o Care including counseling or education had the lowest rates at less than 20%

Patient medication adherence after a hospital discharge averages 1 in 6 to less than one-half The low performance is magnified by the high per capita costs in the U.S. for health care. Quality and cost of care are inversely related on many issues. The “health care system” is in need of reengineering from a fee for service model to a reward for results model. TPH is designed to meet this need. TPH on the scale proposed has not been evaluated and published for review. The components of TPH such as lifestyle coaching, disease management, transitional care management and preventive health services have been evaluated with substantiated savings reported. Generally, high cost, high risk individuals accrue a 25% reduction in medical utilization and costs through high intensity interventions such as transitional care management. Lifestyle habits such as tobacco use, obesity and sedentary behavior have been attributed to account for almost $1,000 per year for each individual in an average population. Health improvement interventions targeting lifestyle habits have consistently reported positive returns on investment approaching a 2:1 ratio. The key determinant to success among these interventions is driving adequate and sustained participation of approximately 50% of a population. The TPH model requires- if not demands a robust and aggressive set of data management solutions. Data points including patient reported outcomes, community based actions, socio economic data as well integrating internal encounter data with external data feeds from vendor and health carriers will be required. The data output must be actionable data for practitioners to use. Data management and information technology infrastructure and human capital investments are key elements for a TPH model. The integration of the best practices and requisite financial investments are foundational issues to be addressed for TPH. The ability to execute the change management process is the most daunting aspect. Reengineering the delivery system, aligning financial incentives and creating a new data model while transitioning from the legacy models to the TPH structure during day to day operations would be challenging for most organizations and may be a taller hurdle for an academic medical center. The ability to lead an organization expeditiously to the tipping point or critical mass where the climate of value and quality is rewarded in order to reach sustainability may be the key factor to increase the likelihood of success.

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Total Population Health

Contents Total Population Health Definition 4

Best Practice Analysis and Methods 5

What are the Problems to Solve? 9

Financial Considerations 10

Total Population Health as the Solution 12

Data Management Solutions 17

Keys to Success in a PCMH Setting 19

Estimating Value 20

MUSC Progress Areas 24

Conclusions 25

References 26

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Total Population Health Definition

The term population health may be generally understood, yet lacks a universally standardized definition. Although a debate over the precise definition may be mundane, it is useful to appreciate the considerations and aspects surrounding the term. The operational term that is suggested for use is “total population health”[1]. The inclusion of the word “total” is intended to eliminate the focus on subsets of a total population that are dominant for any given organization. As an example, population health for the School of Medicine may be interpreted as the faculty, students and support staff. The University Medical Center may outline the population as employees, clinical staff and patients. The term “total population health” is designed to eliminate this provincial approach. A total population includes all individuals who reside within the community of interest. The geographical region that defines the social and cultural fabric of residents is the preferred group to be included in the total population. The tri-county area of Charleston is suggested as the group of individuals who constitute the total population for MUSC Health. Although patients that use a MUSC facility may reside in an area outlying the tri-county region, the difficulty to influence individual health beyond acute and tertiary care justifies the exclusion of these individuals. Thus, the delineation at the tri-county level defines the population within the sphere of significant influence for MUSC Health rather than the “low country” or a geopolitical region such as DHEC VII or even the more expansive South Carolina. The World Health Organization defines health as, a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity [2]. This whole-person concept is a key tenet of the total population health (TPH) approach. The consideration of health beyond the acute issue behind a hospital admission or the chronic disease driving a clinic visit is the foundation of TPH. The investigation and intervention into determinants of degraded health lead to actions and initiatives that are expected to reveal root cause factors and the discovery of gaps in performance for resolution.

A detailed discussion of TPH measurement is included in a subsequent section. Two aspects of TPH are worthy of mention in this definitional preface. The measurement of health for a given population is the aggregation and distribution of morbidity, disability and mortality [2]. The health outcomes of a group of individuals may be considered as a TPH metric [3, 4]. The second aspect of TPH measurement is not commonly found in clinical scorecards. The inclusion of health equity or the health disparity within a population is an evidence based consideration that distinguishes TPH from other measurements [4]. All-cause mortality within a population may be below a normative value and considered favorable performance in aggregate. If within this same population the same measure for an ethnic sub-population or the lower quartile of socio-economic status is five-fold higher than the population average, this creates an unhealthy environment within the population. The measurement of this health disparity has been a key determinant in the total health of nations. As this single measure changes, the overall health scores of a nation are linked [5]. The measurement of this health disparity is intended to drive the consideration of interventions to reduce these disparities. This probably falls under the domain of public health agencies rather than clinicians and medical delivery entities. Discussion of the collaborative initiatives and strategies between a myriad of health agents in the community will be presented in a later section.

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Best Practice Analysis and Methods

The lack of a standardized definition for population health is indicative of the state of evaluation and organizational consistency for TPH. The literature was informative regarding current approaches and suggested strategies to achieve success. There have been components of a TPH strategy with outcomes and suggest a best practice status. The variability between organizations and the lack of universal outcome measure definitions combined with shallow longitudinal data present challenges. The following section outlines suggested approaches when designing a TPH approach. Although a clear consensus or body of evidence to declare best practice status in TPH was not found, the components within a TPH approach has been documented in the literature. Common components of a TPH initiative would be expected to include organizational dynamics, organizational change management, employee incentives, health behavior change and data management principles. All of these topic areas possess a deep and consistent strength of evidence to use as a blueprint within an overall TPH strategy. The recommendations for TPH are derived from several sub-population areas. Patient centered medical homes (PCMH) and accountable care organizations (ACO) are structural entities that serve population health to their respective patient populations. If adhering to the strict definition of TPH, the PCMH and ACO entities would be following a population health approach which is short of the TPH model previously defined. Each checklist or set of recommendations from various organizations will be listed. Then a distillation of these recommendations and findings into a single list has been drafted. A literature review examining the predictive actions within a PCMH environment for application within a TPH was completed [6]. Each recommendation listed also includes the number of references cited in support of the action.

Patients who have a continuous relationship with a personal care physician have better health process measures and outcomes. (5 ref)

Multiple visits over time with the same provider

create renewed opportunities to build management and teaching strategies tailored to individual progress and receptivity. (8 ref)

Minorities become as likely as non-minorities to

receive preventive screening and have their

chronic conditions well managed in a medical home model. (5 ref)

In primary care, patients present at most visits with

multiple problems. (3 ref)

Specialists generate more diagnostic hypotheses within their domain than outside and assign higher probabilities to diagnoses within that domain. (2 ref)

The more attributes of the medical home

demonstrated by a primary care practice, the more likely patients are to be up to date on screening, immunizations, and health habit counseling, and the less likely they are to use emergency rooms [6]. (7 ref)

Increased visits to the PCMH and a visit dedicated as a well-visit are two features associated with improved patient adherence to clinical recommendations [7]. The common notion of adherence to clinical practice guidelines and recommended preventive services is a wide span to address. A National Quality Forum (NQF) environmental scan was performed to discover strong associations between performance and provider practices. The following list outlines general categories of importance for health improvement with TPH [1].

Access to care Patient safety and prevention of adverse/never

events and HAI Chronic disease management Preventable admissions Health literacy Prevention and early diagnosis through health risk

assessments/appraisals and clinical preventive screenings

Chemo-prevention (aspirin) Compliance with prescribed medications

A report issued by the Hospitals in the Pursuit of Excellence (HPOE) affiliated with the American Hospital Association outlined evidence based approaches that associated with successful population health initiatives for member hospitals[4].

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The HPOE also attempted to synthesize their findings into three strategic approaches for TPH.

1. Identify and analyze the distribution of specific health statuses and outcomes with a population. (This can be described as a restatement of the disparity construct.)

2. Identify and implement interventions that modify determinants of health outcomes

3. Identify and evaluate factors that are the causal factors of health outcomes [4]

The HPOE in addition to the structural recommendations and strategic approaches outlined above, introduces a set of must do strategies to support TPH [4].

Aligning hospitals, physicians and other clinical providers across the continuum of care

Utilizing evidence-based practices to improve quality and patient safety

Improving efficiency through productivity and financial management

Developing integrated information systems Joining and growing integrated provider networks

and care systems Educating and engaging employees and

physicians to create leaders Strengthening finances to facilitate reinvestment

and innovation Partnering with payers Advancing an organization through scenario-

based strategic, financial and operational planning Seeking population health improvement through

pursuit of the Triple Aim [4] The following list from HPOE may be more accurately described as tactics [4]. The list complements previous and subsequent checklists and introduces new initiatives to consider.

Value based reimbursement Seamless care across all settings Proactive and systematic patient education Workplace competencies and education on

population health Integrated, comprehensive HIT that supports risk

stratification of patients with real-time accessibility Mature community partnerships to collaborate on

community based solutions There are more detailed tasks recommended by HPOE to support the six above tactics [4]. Value-based reimbursement:

Hospitals and care systems deliver defined services to a specific population at a predetermined price and quality level.

Large hospitals and care systems provide or contract for a full continuum of services across acuity levels for regional populations

Providers link payment contracts and compensation models to performance results

Hospitals and care systems participate in an ACO or PCMH across a significant population

Smaller providers deliver specified services to target populations, working under contract or in partnership within networks that are managed by larger entities functioning as population health managers

Care delivery systems align with the Triple Aim to improve the patient experience of care, improve population health and reduce per capita cost

Seamless care across all settings:

Preventive services are integrated into all care settings

Care transition programs support seamless patient handoffs and excellent communication to reduce readmissions or complications, ensure treatment compliance and engage patients and families as they transition to new settings of care

Care teams or navigators are widely used to assist in managing complicated patient cases across the care continuum

Hospitals and care systems provide care or develop partnerships for care delivery in a community-based setting, such as community clinics or patients’ homes

Small and rural hospitals may utilize telemedicine to connect with remote patients and remote specialty or emergency services

Proactive and systematic patient education:

All patients receive holistic education about disease management and prevention

Education and chronic disease management initiatives target at-risk groups and include medical and behavioral approaches to preventing illness

Multidisciplinary teams of case managers, health coaches and nurses coordinate chronic disease cases, set goals and track progress, and follow up after transitions

Providers use patient-engagement strategies, such as shared decision-making aids, shift-change reports at the bedside, patient and family advisory councils, and health and wellness programs

Providers regularly measure or report on patient and family engagement, with positive results.

Hospitals lead community outreach screening or health education programs

Workplace competencies and education on population health:

Hospitals have leadership and staff dedicated to population health

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Existing staff and clinicians are trained in population health competencies, including working across sectors, aggregating data and identifying systemic issues, and developing policy and environmental solutions

Staff has defined roles within the population health management process

Staff receives ongoing training on population health as it relates to their specific job duties

Hospitals employ care coordinators, community health workers and health educators and augment population health staff as necessary

Integrated, comprehensive HIT that supports risk stratification of patients with real-time accessibility:

HIT possesses capacity for sophisticated analytics for prospective and predictive modeling to support clinical and business decisions

Data warehouse is fully integrated and interoperable, incorporating multiple data types for a variety of care settings (e.g., clinical, financial, demographic, patient experience, participating and nonparticipating providers)

Data from multiple community partners are combined in regional health information exchanges and data registries to comprehensively address the needs of patients and communities

Timely and local data that identify the health issues in a community are accessible by clinical staff in real time to guide the care of individuals

Mature community partnerships to collaborate on community-based solutions:

Hospitals and care systems engage the community by exchanging resources, sharing knowledge and developing relationships and skills to manage community wide challenges and leverage collective advantages

Extensive and diverse partnerships between hospitals and local organizations use collective impact approaches to address specific and general health needs of the community

Hospitals and care systems partner with the community and public health departments to address gaps and limitations in health care delivery and to target community health needs

Hospitals and care systems provide balanced leadership that recognizes the resources and contributions of community partners, and they include community representatives in their leadership structure

Hospital-led initiatives address community issues such as environmental hazards, poverty, unemployment, housing and other socioeconomic factors

Community partners collaborate to develop relevant health metrics to measure progress and community needs

A final evidence recommendation is presented for the health improvement of lifestyle risks. A strategy that is common within TPH is to target individuals who drive upper percentiles of cost. Disease management and case management are typical intervention designs delivered to this high risk – high cost segment of the population. Success measured by health improvement and cost savings has been documented across multiple populations through this approach. There is support replicated primarily in workplace health for an initiative that substantiates the greatest return on investment is found in the maintenance of health among low risk segments [8]. This finding may have unique application for TPH leaders. Although chronic disease and high acuity segments of the population will almost universally be targeted for interventions, the low risk group should probably not merely be considered, but may the most fertile segment for harvested future savings. The factors for driving this cost savings are the low cost and low intensity of interventions to maintain these healthy and low risk segments. This contrasts with dramatically higher costs associated with moving an individual from high risk with multiple risk factors down to a low risk category where costs are also lower. Thus, the long term strategy that may be the most efficient is to keep the healthy low risk. The collective body of these recommendations are restructured, consolidated and presented as a roadmap for consideration to provide an evidence based approach to TPH. Five main themes dominate the recommendations from the various sources. These five do not capture every recommendation outlined above, yet most of the items that fell outside of the primary five were typically more tactical than an overarching suggestion. The five key themes include:

1. Patient Centric Focus 2. Information Technology Reformation 3. Workflow and Delivery System Reengineering 4. Recasting the Sphere of Interest and Influence 5. All-in, Creating Critical Mass to Sustain

Patient Centric Focus The needs of the individual patient must be considered. A reversal of the traditional diagnosis-treat-follow up pattern is suggested. A conversation or dialogue between a multi-disciplinary team and the patient focusing on the goal of health improvement rather than illness fixes captures many of the specific target areas. Information Technology Reformation The radical changes to the patient care, communication, design and measurement of progress requires a new information technology infrastructure and rapid cycle of

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reporting at granular levels previously unheard of in health care. Investments in hardware, software, mobile application design, new expertise and establishing a new climate of support is included in the IT recommendation set. Workflow and Delivery System Reengineering The patient centric focus will drive a new approach to how the individual is viewed as the consumer of services rather than the raw material in the health care process. Proactive communications combined with root-cause analysis are suggested to impact health of the total population as opposed to only the patients treated. Increasing knowledge and awareness to drive higher engagement and activation is recommended. Recasting the Sphere of Interest and Influence A new approach is suggested that forces organizations that were previously competitors or considered irrelevant in daily operations to now become partners. The total population includes residents that are not currently serviced or considered customers/patients. Collaboration with public health and community entities should be integrated as a common practice rather than an adjunct innovation. All-in a Critical Mass to Sustain Arguably one of the greatest challenges will be the pivot from current practices to this new TPH approach. The evidence suggests that a slow and deliberate approach may be a doomed attempt. TPH is a new approach. The requirement to redesign workflows and change practice patterns is difficult to accomplish in a sequential process. Successful organizations created a new climate of change, innovation. Although the change management processes are slower than merely flipping a switch, it appears that an aggressive movement to create adequate critical mass is required to drive sustainability. The evidence supports an aggressive strategy to align the financial incentives for performance is required to support the dramatic investments in energy and resources for TPH. The 65 recommendations have been consolidated to a shorter list within the five themes below.

Patient Centric Create a strong continuous relationship with a

personal care practitioner and drive periodic interactions aligned with patient needs.

Capture patient reported data and integrate with traditional medical claims based data in a single record that is used to create a conversation with each individual.

Build a multi-disciplinary team flowing services and knowledge to the individual that may not be triggered by patient requests.

Information Technology Reformation

Create the infrastructure to store, analyze and deliver on-demand data insights.

Integrate the new patient centered data with claims data and other partner’s data.

Deliver reports and evaluation starting at the individual level and working up to a variety of reporting units.

Include analytical models that allow for sophisticated predictive targeting of individuals before services are required.

Workflow and Delivery System Reengineering

A new system that flips the approach to patient interactions and designs workflows requiring large organizational change to accommodate all changes.

The delivery of services must be seamless and well-coordinated, eliminating duplication and creating new touch-points of care.

A learning organization climate will be critical to support the shift in roles and competencies required to succeed.

Recasting the Sphere of Interest and Influence

Community and public health agencies must now become active partners in the delivery of care.

Determinants or causal factors of degraded health must be identified with efficient initiatives delivered to community segments in greatest need.

A robust patient education system must be in place to deliver appropriate information and personal insights using all community agents in a coordinated fashion.

Outcome measures are developed and reported upon through a consensus building process with the community that frames the TPH geographical territory.

All-in a Critical Mass to Sustain

A quick start strategy combined with a long-view approach is required to drive sustainability.

Human capital investments with other financial resources must be available to flip the organization from a volume focus to a quality climate.

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Problem to be Solved

Where did the discussion originate to develop and design TPH? Why are we attempting to implement a new approach to health care? Is there a need, or is this another repacking of previous attempts at quality improvement to create an appearance of evolutionary progress? A Consumer Purchaser Alliance report states that 91,000 Americans die prematurely for chronic conditions such as diabetes, high blood pressure and heart disease (originally reported by NCQA) [9]. A study published in the New England Journal of Medicine reviewed more than 30 health conditions. Patients received 55% of recommended care, or 45% did not receive recommended care. Patient care rates as low as 11% of recommended care was discovered for alcohol dependence. Care requiring an encounter or other intervention had the highest rates of adherence (73%) and processes involving counseling or education had the lowest rates 18%. A disparity between demographic categories was also documented. The physician office visit rate for females was almost twice as high as males (235 vs. 120). Whites also frequented physician office visits at higher rates compared to blacks (293 vs. 211) [10]. The likelihood of obtaining appropriate care approximates the toss of a coin, a 50/50 proposition. When marital status was examined for associations with quality of life and functionality, individuals who were widowed, separated, or divorced had significantly higher problems across multiple dimensions. Rates of problems for the unemployed are almost twice that of salaried employees [11]. Gender, socio-economic status and race appear to drive medical service utilization that is not substantiated by the same degree of medical need. The study population that drove these data sets was a well-educated group with more than 4 in 10 burdened with a chronic disease. This group would be expected to be more engaged and activated compared to average community residents.

An argument is sometimes presented that individuals with chronic conditions do not appreciate the risks of their disease and become apathetic over time. When medication adherence patterns were examined for individuals discharged from a hospital between 15%-45% of the patients encountered challenges, problems with their medications, yet did not receive appropriate follow-up care [12]. The leading causes of death vary across the life span. Unintentional injuries and suicide dominate veterans, adolescent and young adult mortality. Across all ages, cancer is responsible for approximately 1 in 4 deaths. As we progress into middle age, heart disease, stroke and diabetes are the main factors in mortality and disability. The oldest segment of a population adds chronic obstructive pulmonary disease to the middle age list as primary drivers of death [13]. The scale of the problem dwarfs almost any other social issue in the United States. We are literally discussing life and death as a problem. Almost 1 of every 6 dollars in the U.S. is invested in the care of our health. We are not making requisite improvements as the costs continue to escalate. Even high visibility issues such as breast cancer screening display incremental improvements despite windfall amounts of publicity and awareness. We fail to enforce evidence-based practices that will save lives, such as hand washing (IOM, 2001). We are not modeling other industries that have incorporated safety and best practices into their culture, such as aviation. The health care landscape must be transformed. There are barriers in the interests of many stakeholders within the industry. Roadblocks are present that prevent information transfer between fiduciary agents and the front line practitioners[14]. The naming of this environment as a “health care system” may be an oxymoron. The data and available evidence lead us to the conclusion that we have a problem and a new systematic reformation of care delivery and financial model is dictated. The premise for total population health is hopefully justified.

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Finance The consumption of precious resources and dollars are required to fuel any proposed initiative. This finance section will document savings that have been reported for most of the patient centered interventions that are common in TPH. The literature was lacking in any comprehensive evaluation of TPH. Several medical delivery systems have reported dramatic reductions in inpatient care, readmissions and other services. Many of these reports were reported as quality improvement initiatives. A rigorous financial plan that is integrated with the organizational change strategy will be required for any organization. Cash flow shortages, contract negotiations, human capital compensation as well as training investments must be aligned to reduce financial stress in the organization. The premise for the harvesting of savings within TPH is the reduction of utilization through health improvement. The consideration of high cost clinical issues that present an opportunity to improve are outlined initially. An examination of evidence reporting the impact of lifestyle issues linked to the clinical issues is the second step. The final section will review available studies that have documented savings for various interventions targeting the respective lifestyle behaviors and clinical issues. Note: The dollars represented in the various literatures below have not been adjusted to 2014 dollars. The expenses or savings are noted unadjusted from the original reporting source. The intent is to review relative success or failure and not create a forecast of savings for any organization or year. A separate MUSC Health model will need to be constructed with the most current prevalence, incidence and costs. An analysis of costs at Kaiser Permanente in 1995-1996 was completed and a summary of the cost areas is below [15]. The highest cost per diagnosed condition with high probability of potential savings has been extracted from the larger data set.

Renal failure $22,636 Heart Failure $18,208 Colorectal cancer $15,253 IHD $11,981 Breast Cancer $ 6,672 Depression $ 5,440 Pregnancy $ 4,407

Considering all costs the percentage of the total that each respective area consumes provides additional perspective. The top ten are below. These top ten account for approximately 70% of all attributable costs.

Injury, poisoning, low back pain 14.5% Respiratory 8.6% Behavioral health 8.5% OB/GYN 8.3% Ischemic heart disease 6.8% Hypertension 5.7% Heart Failure 4.0% Diabetes 3.7% Cancers 3.4% Renal Failure 3.2%

An analysis of TRICARE beneficiaries was completed across several years with different data sets. These TRICARE studies were selected to improve consistency and comparability. The costs for chronic conditions were the focus of the first study. For individuals in the age band 45-54 years of age the follow additional costs per year per person were reported [16].

Colorectal cancer $31,932 Heart Failure $ 8,791 Breast Cancer $ 8,375 CHD $ 3,859 Diabetes, $ 1,302

The TPH strategies typically highlight personal lifestyle behaviors as opportunities to generate savings. A study examining excess costs for obesity, high alcohol consumption and tobacco use is outlined below [16]. Annual costs associated with overweight and obesity. Attributable costs above average.

Cerebrovascular $5,871 Cardiovascular disease $4,399 Diabetes $1,684 Hyperlipidemia $ 233 Hypertension $ 941

Annual costs associated with tobacco use. Attributable costs above average.

New born conditions (n=150) $14,488 Cerebrovascular disease $ 6,129 Cardiovascular disease $ 4,163

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When the lifestyle issue costs are aggregated and then spread over the entire population the average per person per year costs are below.

Alcohol use $386 Overweight and Obesity $305 Tobacco use $204 Total $895

The premise for savings generated through lifestyle interventions has been established. High costs and high volume conditions influenced by common unhealthy lifestyle behaviors is expected to justify interventions with subsequent savings produced. The literature is replete with more than 25 years of studies, predominantly in worksite based programs and more recently in Medicaid and Medicare populations. The review for this monograph was not exhaustive. The literature cited was intended to be illustrative and consistent. The advantage of the TRICARE data is the large size of the population (n=4.3 million) compared to most studies with populations approximately 1/10th to 1/20th of the TRICARE data. Highlights of the savings findings are below.

A 1% reduction in body weight that is maintained results in a lifetime savings of $440 per individual. A discount rate of 3%, future monetary value is assumed [17].

A 10% reduction in body weight for an

adult <45 years of age results in a net $6,400 lifetime savings. $1,700 in costs for additional longevity are factored into this calculation [17]. ($8,100 gross savings)

Average short term program effect for

participants per year [17]. o Asthma $453 o Heart Failure $371 o Diabetes $783

Lifestyle management vendor reported savings across 28,000 participants in wellness and 920 Disease Management participants [18]. Stated as per program participant per month.

Health Promotion – Lifestyle Savings $61 Disease Management Savings $12

A range of return on investment calculations are reported in the literature. Assuming a publication bias exists in this area and other unfavorable studies have been excluded due to this bias, it may be safe to state that the following are considered best case scenarios. A health plan evaluation of health promotion and disease management interventions with a population size of approximately 300,000 over an eight year study was evaluated. Approximately 15,000 participants were noted [19].

Annual ROI ranged from 1.7 to 2.8 Average ROI 2.0 Total Savings $6 million

Program participants in asthma or heart failure or diabetes disease management programs [20]

ROI 1.26

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Total Population Health as a Solution The theoretical foundation and various constructs of TPH have been outlined and referenced in previous sections. Needs have been identified, gaps in current approaches and best practices with documented savings have been noted. This section will begin to provide additional details regarding the “front-line” initiatives and activities intended to bring the TPH framework into action. Major initiative areas will be outlined to allow for insights into the design and approach recommended. This would be considered a jump-off point for a TPH program. Additional initiatives and interventions would be expected as the clinical practice workflow engineering and patients’ needs of the population are integrated into the TPH program design. Counseling and Education The multi-disciplinary clinical practice team is suggested as a best practice and proposed to improve the frequency and effectiveness of patient counseling and education. Provide training and education on two behavioral change models as standard approaches by health educators and practitioners as applicable. Four approaches will be emphasized to establish a standardized approach with the practice teams.

1. Create consensus clinical guidelines for counseling and education for preventive services and lifestyle behaviors.

2. Initially the patient interaction follows the 3A acronym; ask-advice-assist. This is a modified version of the more widely published 5A model well established in tobacco cessation counseling [21, 22].The workflow template aligns clinician to patient interactions as a three step action.

3. The Health Action Process Approach (HAPA) is a synthesis construct of multiple theories into a single framework for counseling [23, 24].

4. An alternative framework that may serve practitioners as an effective patient approach is Motivational Interviewing (MI) [25].

The recommended action is for the practitioner to facilitate a referral to a qualified health educator who will incorporate either HAPA or MI as the framework for the counseling session.

The science of health education and health behavior application is wide ranging, constantly evolving and reflects both commonalities and includes contradictions when considering the myriad of theoretical approaches. The social sciences including psychology, sociology, communications and marketing are influenced by the translation into practice by the fields of nursing, health education, medicine and health sciences [26]. TPH may include numerous approaches and when designing specific patient communications or conversations certain behavior change models will be preferred based on the topic the context and familiarity with the theory by the user. Lifestyle Management Lifestyle management (LM) is sometimes referred to as health coaching. A common description in the literature for these services falls under the label wellness or health promotion. Health education professionals from one of a variety of allied health professions typically staff the health coaching teams (health educators, exercise physiologists, dietitians, tobacco cessation counselors, social workers, behaviorists and registered nurses). The most common lifestyle issues considered for health coaching intervention include:

• Body Fat – Obesity • Sedentary Behavior – Active Lifestyle • Tobacco Use – Smoking & Smokeless • Stress • Alcohol and Substance Abuse • Nutrition – Dietary Intake

On-site/personal face to face coaching and telephonic coaching are the most common venues for this intervention [27]. Increasingly, the use of the Internet and other electronic delivery of coaching services have been reported [28, 29].

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Disease Management Disease management (DM) is commonly targeted at individual with a chronic disease diagnosis who are considered at risk for immediate high cost consumption of services [18-20, 30]. The higher acuity of patients has typically driven registered nurses to serve as the phone based counselors. Disease and case management teams have also been implemented in primary care settings [31]. The preferred activation model is referred to as an “opt-out” feature. The individual is required to decline services when engaged. The opposing model is an “opt-in” feature where the individual must make the initial action and request enrollment in a program. Opt-out design programs have reported participation levels above 80% compared to opt-in programs of less than 20% and sometimes as low as the single digits [30]. Complex Case, Transitional Care, (Extreme) Case Management The health improvement activities for individuals with extreme utilization of medical services falls under several intervention categories including: complex case management, transitional care (from hospital to home), and health care management. Services are coordinated with an experienced case manager, typically a registered nurse as a certified case manager [31, 32]. A rationale for recruiting patients into case management is the complexity of their health and social profile. As an example, analyzing claims for individuals with diabetes, the majority of medical costs were associated with the complications of diabetes and not the diabetes diagnostic or treatment services [20]. The interventions and outcomes as informed by the literature have mixed effects. The targeting of specific risk factors or functional difficulties is associated with increased effectiveness [31]. Community Collaboration The collaboration with community agencies, public health entities and various task forces or regional coalitions are areas that may be the weakest for most TPH organizations. A deep and robust literature is informative on this strategy. The literature is formed from areas such as Community Based Participative Research (CBPR) as well as the community visioning processes and community-wide goal development. Several innovative mechanisms have been reported that

substantiate the success of TPH through community collaboration. A frequent feature of several reported models is the creation of health workers who are physically based in the heart of the community. Typically the underserved residential areas are likely locations for these workers. These community health workers are employees of the TPH organization and support the needs of the residents as a first priority and are viewed as equitable agents of care rather than self-serving to the TPH organization. A Pathways model in Ohio has placed a heavy emphasis creating a care path for specific issues within the community. The best practice feature for emphasis is the flow of data from the individual to the TPH entity that includes services and interactions with community agencies [33]. A comparable coalition approach is described as an envelope that contains all medical delivery, public health, community agency, payor and employer data within a common geographic location [34, 35]. These structures have been labeled Population Health Organizations or PHOs. Hacker and Walker have suggested eight steps to develop collaborative relationships between an ACO and the community, specifically public health entities [36].

1. Determine in which geographic communities patients reside and what the overlap is between the ACO panel and the community population.

2. Compare the health of the population served by the ACO with that of the community.

3. Decide what level of overlap in any geographic area merits collaboration. The more market share an ACO has in the area, the more investment in collaboration might be made, and the more impact that investment will have on health outcomes.

4. Engage in collaboration with public health and key community agencies, including conducting a joint needs assessment.

5. Collaboratively select health outcomes for focus.

6. Set up a formal agreement with the public health authorities to share data and monitor progress toward goals in clinical and community settings.

7. Identify population health indicators to be included on the ACO dashboard.

8. Use a portion of global payment fee to support community public health activities.

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Community and Home Outreach Public health organizations and home-care agencies have a long record of performance with community based and home interventions [34]. The integration of these activities into the seamless TPH approach is desired. The patient interaction in their natural environment allows for the discovery of social and personal health determinants at a granular level that is virtually impossible to ascertain in a provider location. A potentially insightful qualitative research study revealed several common determinants among high or super users of emergency department visits. Insights of social determinants for this group of super users included previous disrespect from providers, socio-economic discrimination, previous provider distrust, parental loss, transiency and a history of abusive relationships. Participants in this study expressed that they felt that their care sometimes was compromised by perceived disrespect from health care providers, citing race-sex- or SES based discrimination. Prior studies have noted that patients may respond to this sense of disrespect or distrust from providers with decreased adherence to medication regimens, refusal of services, or delays in care. abusive relationships, childhood instability, parental loss, and transiency characterized the majority of the participants [37]. An intense discharge planning program included a 4-week intervention composed of a hospital visit, a home visit and 3 follow up telephone calls.

Peer Modeling and Social Support The use of peers to establish a lay network of social support, informed education has been used across a variety of clinical issues. These peers help increase the self-efficacy and improve behavioral intentions with downstream higher rates of sustained behavior change [38, 39]. This approach has also been replicated in electronic communications and more recently social media [40]. Peer modeling and the establishment of social support structures involves is based on the evidence derived from social cognitive behavioral theories [38, 39].

Behavioral Economics The science and evidence that describes the risk evaluation process in health related decision making falls under the category of behavioral economics. The body of literature has several basic tenets that are key to understanding patient communication and the personal health decision making process [41].

Consider the central finding of prospect theory, that aversive events have a greater impact on choice than benefits [41].

The behavioral process individual’s exhibit will discount the benefits of a healthy decision similar to our discounting money in financial decisions. Thus, the benefits of physical activity for future health are discounted and the relative value of the status quo is higher. The term hyperbolic delay discounting is a theory that explains health behaviors as irrational from a normative economic perspective[42].

The previous points are outlined to emphasize the complex sometimes irrational cognitive process patients follow when faced with health care decisions. The use of specialists in health education and health behavior are promoted to create efficiency and maximum effectiveness.

Faith Based Collaboration Points of intersection between the faith based and public health sectors [43]

• Congregational based health promotion and disease prevention

• Denominational based primary care • Medical and public health missions • Federal faith based initiatives • Community based outreach to special

populations • Population health research on

religiousness • Academic faith and health centers • Faith based health policy and advocacy

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Evidence Based Collaborative and Community Approaches

A recommended approach with both internal and community stakeholders is the reliance on evidence-based or best practice models for health improvement. The use of these national or state based programs is efficiency and improved collaboration. The following program list is not intended to be exhaustive although the key lifestyle issues are addressed through these initiatives. Condition specific issues such as cancer, asthma or less incident conditions or rare diseases have not been included in this list. It is expected that the higher volume issues that drive medical care utilization will be included in the overall TPH approach. A more detailed analysis of the data should be completed to select the short list of issues that will be added to the TPH approach for a given total population. Exercise is Medicine™ Evidence-based approaches aimed at increasing physical activity (PA) at the population level, including policy and environmental interventions, and programs in the workplace and community, have been identified. However, most have modest effect sizes, suggesting that no single intervention will solve our growing physical inactivity problem. Reducing physical inactivity most likely requires a more comprehensive, ‘whole of society’ approach. Efforts are needed to maximize the potential benefits of setting-specific interventions, under a coordinated, multi-sector approach and "healthcare providers have contact with the majority of Americans [giving them] a unique opportunity to encourage PA among their patients through PA assessment and brief counseling [44]. Healthy People 2020 The national strategic documentation formally produced by the joint agencies of the U.S. (CDC, DHHS) is outlined in along specific categories and performance objectives. The objectives are established as a goal for the year 2020. The goals and subsequent interventions based on available evidence are covered within the Community Guide to Preventive Services. The Guide to Community Preventive Services is a free resource to help you choose programs and policies to improve health and prevent disease in your community. Systematic reviews are used to answer these questions:

• Which program and policy interventions have been proven effective?

• Are there effective interventions that are right for my community?

• What might effective interventions cost; what is the likely return on investment? [45]

SPARK A physical education initiative for schools using non-physical education teachers and available resources was created and evaluating. The SPARK program has proven effective as a low-cost efficient program to implement in schools [46]. Eat Smart – Move More Charleston Tri-County Coalition Decreasing obesity in our state is a collaborative effort. No one person or group can do it alone. That’s why we work with all South Carolina communities and our partners. Below is a short list of partners that we work directly within specific settings, and the menu on the right provides many overviews and articles on what communities are doing to fight obesity and to help make the healthy choice, the easy choice. S.C. Farm to School The South Carolina Farm to School Program supports schools in implementing the four components of Farm to School. Participating schools are required to: 1) source at least two SC grown fruits and vegetables per month to be served as a part of the school meal; 2) promote SC grown in the school cafeteria; 3) integrate nutrition and agriculture education into classroom activities; and 4) establish a school vegetable garden. Coordinated Approach to Child Health (CATCH) The CATCH Program brings schools, families, and communities together to teach children how to be healthy for a lifetime. Healthy behaviors are reinforced through a coordinated approach – in the classroom, in the cafeteria, in physical education, at home and after school. CATCH includes a K-8 grade classroom health education curriculum, as well as Early Childhood and After School curricula.

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S.C. Safe Routes to School Safe Routes to School (SRTS) is a growing movement across the US that brings together parents, schools, and community leaders to encourage students, including those with disabilities, to walk and bike to school. SRTS activities and resources focus on improving walking and biking conditions around schools while building healthy habits and safety skills. Alliance for a Healthier Generation The Alliance for a Healthier Generation’s Healthy Schools Program is a program designed to create healthy schools. It makes big changes with committed efforts from the individuals involved: school faculty, teachers, students, and parents. The Program is based on a framework created in partnership with the American Heart Association, and it’s the largest program focused on the issue of childhood obesity in schools. Faithful Families Eating Smart and Moving More The Faithful Families Eating Smart and Moving More Program promotes healthy eating and physical activity in communities of faith. The Program addresses the problem of overweight and obesity by promoting healthy eating and physical activity through implementation of research-based policies, programs and environmental changes. CDC – We Can! We Can! Is collaboration between the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, and the National Cancer Institute. We Can! (Ways to Enhance Children's Activity & Nutrition) is a national movement designed to give parents, caregivers, and entire communities a way to help children 8 to 13 years old stay at a healthy weight. Research shows that parents and caregivers are the primary influence on this age group. The We Can! national education program provides parents and caregivers with tools, fun activities, and more to help them encourage healthy eating, increased physical activity, and reduced time sitting in front of the screen (TV or computer) in their entire family.

Let’s Go 5-2-1-0 Let’s Go! Is a nationally recognized childhood obesity prevention program. The goal is to increase physical activity and healthy eating for children from birth to 18 through policy and environmental change. Let’s Go! Works in six sectors to reach families where they live, study, work and play to reinforce the importance of healthy eating and physical activity. The 5210 message (5 or more fruits and vegetables, 2 hours or less of recreational screen time, 1 hour or more of physical activity and 0 sugary drinks, more water and low fat milk a day) is used consistently across all sectors. ACTIVE Living Community Increasing the number of citizens who meet daily physical activity recommendations through use of the built environment, land-use mix diversity, walking safety [47]. Clinical Practice Guidelines Use of guidelines developed by physician peers and tailored to local preferences yet maintaining national consensus standards [48].

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Data Management Solutions

The management of data and flow of information from collection and storage through to reporting and evaluation is a long and complex journey. The concept of total population health assumes that adequate measurement of health outcomes, determinant factors of health, patient reported outcomes can all be collected, tracked, reported and evaluated [1]. The following section is intended to provide a representative description of many aspects of TPH data management. Although this is not a detailed road-map of actions and strategy the intent is to provide sufficient detail to appreciate the approach strategy. The measurement aspects of preventive services, lifestyle behaviors and medical utilization have been previously outlined. The selections of performance areas to measure, the methodology for the data flow are areas that must be considered. The initial consideration is data captured for current health status combined with the desire to measure longitudinal trends overlaid with the need to forecast future health trends. Incidence-based measures are generally more useful for monitoring trends and predicting future needs. Prevalence-based measures are useful in planning for current needs. Mortality rates are an outcome and incident event [2]. The potential error in reporting occurs when we measure an aspect of health that is different than our intended outcome. As an example, when we compare two individuals on health performance we can derive opposing conclusions dependent on the measurement criteria. If two individuals – Ann and Betty are assessed and Ann is healthier than Betty currently, let’s consider future health data measurement. After Ann and Betty have died, will Ann have lived a health life than Betty? After we assess that Ann was initially healthier, will Ann have a healthier life than Betty? What is the influence of the age of death under these scenarios? These scenarios are designed to highlight the challenges of population health measures. Any measure is formed from a single perspective such as longevity and does not consider other aspects of total population health [2].

Some of these considerations can be illustrated as a set of contrasting measures [2].

1. Life table population vs. real population 2. Health expectancy vs. health gap 3. Generic vs. disease specific

epidemiological input 4. Types of value or valuation procedures for

expressing disability and disease in time units

5. Incidence vs. prevalence 6. Other utilization or patient reported values

Major health problems in the U.S. were identified in Sept 1983 by an expert panel using 5 criteria

1. Point prevalence and temporal trends 2. Severity of health impact and cost 3. Sensitivity to intervention using current

scientific or operational knowledge 4. Feasibility of such interventions 5. Generic applicability of such interventions

to other health problems [Cited by Mahapatra in [2], section 2.5]

A consolidated list of categories and sample measures was extracted from the literature [2, 11, 13, 49]. Mortality

Deaths, crude death rate, standardized mortality ratio, years of potential life lost before the age of 65

Morbidity Incidence rate, annual period prevalence, hospitalizations, physician visits, days lost from work, low birth rates

Complications Blindness, paralysis, amputations

Quality of Life Patient reported functionality and quality of life Family, transportation to health facility Social, greater dependency

Demographic Age, gender, ethnicity, race, location of residence, marital status

Socio Economic Measures Educations, disposable income, gross income, household income, occupation, and savings

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Inferred from previous categories are outcomes and early indicators. Stated differently there are process of care measures and clinical outcome measures. We also have measures that report the patients’ experience and individual physician or practitioner level performance [9]. The list of multiple perspectives and various indicators continues to grow as we dig deeper into the available literature. The ultimate balance is a list of measures that captures an accurate cross section of performance without a length that is unwieldy or too broad to deliver an accurate assessment of TPH outcomes [13]. A study that provided several insights into total population health investigated Manitoba Canada in the mid-1990s [13]. Salient extracts follow.

Small populations can be reported over a five-year period to increase credibility

Hospitals reported 28%-42% of care delivered to patients outside their region of residence

Elderly residents without a physician visit within 24 months tend to be healthy

Calculated rates use the total services in the denominator. Diabetes admissions/total admissions

A standardized mortality ratio (SMR) when used, overcome the need to adjust for population differences

The SMR used age 0-64 death rate as the comparative

Most rates are reported by gender Premature mortality is the measure used

most frequently to summarize population health status

Poor threshold commonly used; 2 diagnosis within 24 months with 3 or more chronic diagnosis

Poor health was strongly related to adverse material circumstances – low SES, social support

According to the WHO, youth is defined as younger than 24 years of age, elderly are persons 75 years of age or older

Most common indicators and measures used to assess total population health, the determinants of health, and health improvement activities from a representative subset of indicator reports [1] (n=26 reports).

Overall Obesity Smoking prevalence Physical activity Excessive drinking of alcohol Healthy diet/nutrition Cancer screenings – colorectal, cervical, and breast Immunizations – childhood, influenza, and pneumococcal Insurance coverage Unmet clinical care needs Prenatal care services received Oral health care services received

By Domain

Infant mortality Low birth weight/very low birth weight Teen pregnancy rate Mortality and hospitalizations due to injury (aggregate measure) Suicide rate Mortality from motor vehicle accidents Cancer mortality rates Diabetes prevalence rates Cancer incidence rates Obesity Depression Smoking prevalence Physical activity Excessive drinking Healthy diet/nutrition Breast feeding Cancer screenings – colorectal, cervical, and breast Immunizations – childhood, influenza, and pneumococcal Insurance coverage Unmet clinical care needs Usual primary care provider Air quality index High school graduation rate Poverty level Hospitalizations for preventable admissions (aggregate measure) Prenatal care received Oral health care received Diabetes management received Heart attack care received Depression/mental health care received

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Keys to Success in Population Health in a PCMH-ACO Setting

Community Care of North Carolina The state Medicaid program in North Carolina, titled Community Care of North Carolina has engaged physician networks in PCMH reimbursement methods and sponsored quality improvement initiatives that have produced dramatic results. A per-member per-month management fee is provided to physician networks that agree to use evidence based guidelines in the delivery of care to patients. A minimum of three conditions are required to generate the PMPM subsidy. Performance data is also required from the participating physician networks. A one-page performance report is forwarded to each physician quarterly. The performance report includes metrics on financial and quality improvement standards for medical and pharmaceutical categories. Highlights of savings reported by this PCMH include the following. Asthma Care

$3.5 million savings 3 year program evaluation period 34% reduction in asthma hospital

admission rate 8% reduction in emergency department

visit rate for asthma care 24% reduction in average episode cost

($687 versus $853) Diabetes Care

$2.1 million savings 7% increase in dilated eye exams 23% increase in foot examinations

Prescription Initiative

$1 million in savings during first 6 months of 2005

Overall Savings

$60 million in 2003 $124 million in 2004 $231 million in 2005 and 2006 2007 data indicates continued

improvement in trends, final analysis not released

Analysis conducted by Mercer

Erie County New York Medicaid – Medicare The county department of health for Erie County, including Buffalo, NY started a primary care partial capitation program in 1990. Patients who were dual eligible Medicaid-Medicare with chronic disabilities were selected as the eligible population. A PMPM management fee was instituted for primary care physicians. The reported savings was $1,000 per patient [1]. Duke School of Medicine Duke SOM launched its primary care leadership track in 2011. Special components of the program include a longitudinal clerkship in primary care offices, training in the patient centered medical home model community service, research in community engaged population health and leadership training. Curriculum based on the principles and skills of population health improvement. Four domains are public health, critical thinking, community engagement, and team skills [50]. Tennessee Peer Link Peer Link members in Tennessee in the months prior to entering the program was 7.42 according to preliminary outcome figures, after involvement in the program, the number of hospitalization days decrease to 1.9 or by 73% (n=38) North Carolina PCMH North Carolina PCMH across a five-year longitudinal study [51].

Savings in year 1 of $191 PMPM Savings in year 5 of $64 PMPM 1.7 million enrolled Total Savings $184 million Net PMPM reduction of 7.8%

Nova Health IPA – Aetna ACO Approach Maine provider group contracted with Aetna for 750 Medicare Advantage Members [52].

Admissions reduced 45% Hospital days/1000 reduced 50%

Geisinger PCMH Geisinger PCMH self-reported experience of care more favorable and with preferred place of service choices. Patient perceptions of PCP performance and interactions were not different than non-PCMH patients [53].

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MUSC Progress Areas

MUSC Health is actively working to improve the health of various populations. Below are highlights of some programs and initiatives that are indicative of population health care delivery. As the organization moves forward additional initiatives and workflows will evolve and the integration between all programs is expected to increase. Transitional Case Management, STAR Program Case managers address the needs of the patients from a total person view. Similar to socio-cultural approach is a hallmark construct within all total population health strategies. Case manager identify determinants of health and facilitate both MUSC and community resources to assist patients and reduce readmissions and illness relapse. Healthy Outcomes Program Patients are recruited to participate in this state subsidized program. The subsidy level is a

fraction of total care, placing MUSC Health “at-risk” for total care of the patient. The focus is on improving the health of patients and facilitating the resolution of issues limiting access and patient engagement. These patients are considered to be high risk for extreme levels of medical services consumption. A multi-disciplinary team has been planned to intervene with the patient and problem-solve issues to improve quality of life, health associated with lower total costs. Healthy Connections Check Up Healthy Connections is a state funded program that allows for an annual preventive care visit and family planning counseling. The fee for service funding mechanism rewards MUSC providers for recruiting and delivering care to these high need patients within the Medicaid eligible population. The TPH strategy of engaging individuals who are moderate risk and assisting in maintaining health before illness appears is the driving force for Healthy Connections.

Coastal Connections Coastal Connections is a nonprofit located in MUSC that aims to remedy problems caused by health determinants, such as homelessness or lack of adequate food. Coastal Connections is a free, volunteer-based program that connects qualified patients in MUSC hospitals and clinics to local resources. The Coastal Connection staff work with community partners to help secure patients with food, housing, clothing, healthcare and more. These resources, in turn, have the potential improve clients’ health and overall quality of life. PASO PASO is a state-wide non-profit in South Carolina that works to address the health issues of the Hispanic community free of cost. At MUSC, PASOs is situated in the Nursing Department. PASOs’ Care Navigators help to assist clients with Medicaid, SNAP, TANF, or WIC enrollment, searching for medical services or a medical home, understanding Family Planning Methods, and with finding classes in English or literacy. Care

Navigators also offer lectures on various health topics such as free medical clinics and rights regarding health and community services. Patient Centered Medical Homes Internal Medicine and Family Medicine clinical teams have adopted the principles of TPH through the Patient Centered Medical Homes (PCMH) model. These clinical teams have obtained accredited status through the National Committee for Quality Assurance (NCQA) as level three PCMH systems. The support of the patient through a multi-disciplinary medical home as a key tenet of TPH continues to evolve and improve care here at MUSC Health. Aggressive Patient Education and Counseling The use of health education and behavior change specialists for tobacco cessation and pharmacist counseling for high need and poly pharmacy issues is initiated for hospital patients. The extended care beyond discharge for patients is an example of how a TPH approach follows through for specific patient needs.

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Conclusions TPH has tremendous promise and appears to resolve many issues that challenge the delivery system in the current environment. The gaps in care have been documented by numerous sources. Savings have been harvested at the program component level for almost every proposed intervention in the TPH model. Change management science provides a framework to institute the many recommendations. A robust and detailed plan to coordinate the multi-factorial approach across a complex and diverse academic medical center such as the MUSC landscape will be required to increase the likelihood of success. The integration of the best

practices and requisite financial investments are foundational issues to be addressed for TPH. A significant challenge for TPH is reengineering the delivery system, aligning financial incentives and creating a new data model. Simultaneously, transitioning from the legacy models of care to the TPH structure during day to day operations would be challenging for most organizations and may be a taller hurdle for an academic medical center. The ability to lead an organization expeditiously to the tipping point or critical mass where the climate of value and quality is rewarded in order to reach sustainability is a key factor to increase the likelihood of success.

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References 1. Jacobson, D.M. and S. Teutsch An environmental scan of integrated approaches for defining and measuring total population health. 2012. 58. 2. Murray, C.J.L., et al., Summary Measures of Population Health, ed. C.J.L. Murray. 2002, Geneva: World Health Organization. 770. 3. Gourevitch, M.N., Population health and the academic medical center: the time is right. Academic Medicine, 2014. 89(4): p. 6. 4. Trust, H.R.E. The second curve of population health. 2014. 5. Hancock, T., R. Labonte, and R. Edwards, Indicators that count! - measuring population health at the community level. 2000, Centre for Health Promotion: Toronto. p. 88. 6. Rosenthal, T.C., The medical home: growing evidence to support a new approach to primary care. Journal of the American Board of Family Medicine, 2008. 21(5): p. 14. 7. Ferrante, J.M., et al., Principles of the patient-centered medical home and preventive services delivery. Annals of Family Medicine, 2010. 8(2): p. 9. 8. Musich, S., et al., A more generalizable method to evaluate changes in health care costs with changes in health risks among employers of all sizes. Population Health Management, 2014. 17(5): p. 10. 9. Improving Health Care Through Transparency & performance Measurement. 2014 July 2014; Available from: http://www.consumerpurchaser.org/images/documents/MB.pdf. 10. McGlynn, E.A., et al., The quality of health care delivered to adults in the United States. The New England Journal of Medicine, 2003. 348(26): p. 11. 11. Kind, P., et al., Variations in population health status: results from a United Kingdom national questionnaire survey. British Medical Journal, 1998. 316: p. 6. 12. Coleman, E.A., S.A. Rosenbek, and S.P. Roman, Disseminating evidence-based care into practice. Population Health Management, 2013. 16(4): p. 9. 13. Cohen, M.M. and L. MacWilliam, Measuring the health of the Population. Medical Care, 1995. 33(12): p. 22. 14. Eggleston, E.M. and J.A. Finkelstein, Finding the role of health care in population health. Journal of the American Medical Association, 2014. 311(8): p. 2. 15. Ray, G.T., et al., The cost of health conditions in a health maintenance organization. Medical Care Research and Review, 2000. 57(1): p. 18. 16. Dall, T.M., et al., Cost associated with being overweight and with obesity, high alcohol consumption, and tobacco use with the military health system's TRICARE Prime-enrolled population. American Journal of health Promotion, 2007. 22(2): p. 20. 17. Dall, T.M., et al., Weight loss and lifetime medical expenditures. American Journal of Preventive Medicine, 2011. 40(3): p. 7. 18. Grossmeier, J., et al., Impact of a comprehensive population health management program on health care costs. Journal of Occupational and Environmental Medicine, 2013. 55(6): p. 10. 19. Schwartz, S.M., et al., Sustained economic value of a wellness and disease prevention program: an 8-year longitudinal evaluation. Population Health Management, 2014. 17(2): p. 11. 20. Dall, T.M., et al., Outcomes and lessons learned from evaluating TRICARE's disease management programs. American Journal of Managed Care, 2010. 16(6): p. 9. 21. Hung, D.Y., R. Leidig, and D.R. Shelley, What's in a setting?: influence of organizational culture on provider adherence to clinical guidelines for treating tobacco use. Health Care Manage Rev, 2014. 39(2): p. 154-63. 22. Spring, B., et al., Better population health through behavior change in adults: a call to action. Circulation, 2013. 128: p. 8. 23. Chiu, C.-Y., et al., The health action process approach as a motivational model for physical activity self-management for people with multiple sclerosis: a path analysis. Rehabilitation Psychology, 2011. 56(3): p. 12. 24. Parschau, L., et al., Physical activity among adults with obesity: testing the health action process approach. Rehabilitation Psychology, 2014. 59(1): p. 9. 25. Cucciare, M.A., et al., Teaching motivational interviewing to primary care staff in the Veterans Health Administration. J Gen Intern Med, 2012. 27(8): p. 953-61. 26. Glanz, K., B.K. Rimer, and F.M. Lewis, Health behavior and health education. 2002, San Francisco: John Wiley & Sons. 583. 27. Palmer, S. and A. Whybrow, Practice briefing. health coaching to facilitate the promotiion of health behavior and achievement of health-related goals. International Journal of Health Promotion and Education, 2003. 41(3): p. 4.

23

28. Eysenbach, G., Persuasive system design does matter: a systematic review of adherence to web-based interventions. Journal of Medical Internet Research, 2012. 14(6): p. 37. 29. Lyden, J.R., et al., Implementing health information technology in a patient-centered manner: patient experiences with an online evidence-based lifestyle intervention. J Healthc Qual, 2013. 35(5): p. 47-57. 30. Lynch, W.D., et al., Documenting participation in an employer-sponsored disease management program: selection, exclusion, attrition, and active engagement as possible metrics. Journal of Occupational and Environmental Medicine, 2006. 48(5): p. 8. 31. Smith, S.M., et al., Managing patients with multimorbidity: systematic review of interventions in primary care and community settings. Bmj, 2012. 345: p. e5205. 32. Tahan, H.A. and V. Campagna, Case management roles and functions across various settings and professional disciplines. Prof Case Manag, 2010. 15(5): p. 245-77; quiz 278-9. 33. Zeigler, B.P., et al., Pathways community HUB: a model for coordination of community health care. Population Health Management, 2014. 17(4): p. 9. 34. Clark, N.M., et al., Improvements in Health Care Use Associated With Community Coalitions: Long-Term Results of the Allies Against Asthma Initiative. American Journal of Public Health, 2013. 103(6): p. 1124-1127. 35. Yasnoff, W.A., E.H. Shortliffe, and S.M. Shortell, A proposal for financially sustainable population health organizations. Population Health Management, 2014. 17(5): p. 2. 36. Hacker, K. and D.K. Walker, Achieving population health in accountable care organizations. American Journal of Public Health, 2013. 103(7): p. 5. 37. Mautner, D.B., et al., Generating hypthoses about care needs of high utilizers: lessons from patient interviews. Population Health Management, 2013. 16(S1): p. 9. 38. Solomon, P., Peer support/peer provided services underlying processes, benefits, and critical ingredients. Psychiatr Rehabil J, 2004. 27(4): p. 392-401. 39. Uchino, B.N., Social support and health: a review of physiological processes potentially underlying links to disease outcomes. J Behav Med, 2006. 29(4): p. 377-87. 40. Niederdeppe, J., et al., Effects of messages emphasizing environmental determinants of obesity on intentions to engage in diet and exercise behaviors, in Preventing Chronic Disease. 2013, Centers for Disease Control: Atlanta. p. 11. 41. Francisco, M.T., G.J. Madden, and J. Borrero, Behavioral economics: principles, procedures, and utility for applied behavior analysis. The Behavior Analyst Today, 2010. 10(2): p. 18. 42. Kahneman, D. and A. Tversky, Prospect theory: an anlalysis of decision under risk. Econometrica, 1979. 47(2): p. 33. 43. Levin, J., Faith-based partnerships for population health: challenges, initiatives, and prospects. Public Health Reports, 2014. 129: p. 4. 44. Coleman, K.J., et al., Initial validation of an exercise "vital sign" in electronic medical records. Medicine & Science in Sports & Exercise, 2012. 44(11): p. 6. 45. Koh, H.K., C.R. Blakey, and A.Y. Roper, Healthy People 2020: a report card on the health of the nation. Jama, 2014. 311(24): p. 2475-6. 46. McKenzie, T.L., et al., Long-term effects of a physical education curriculum and staff development program: SPARK. Res Q Exerc Sport, 1997. 68(4): p. 280-91. 47. Gell, N.M. and D.D. Wadsworth, How do they do it: working women meeting physicial activity recommendations. American Journal of Health Behavior, 2014. 38(2): p. 11. 48. Eden, J., et al., Knowing What Works in Health Care: A Roadmap for the Nation, ed. I.o.M.o.t.N. Academies. 2008, Washington, DC: National Academies Press. 49. Sherbourne, C.D. and A.L. Stewart, The MOS social support survey. Social Science Medicine, 1991. 32(6): p. 10. 50. Sheline, B., et al., Population health initiatives for primary care at Duke University School of Medicine. North Carolina Medical Journal, 2014. 75(1): p. 3. 51. Fillmore, H., et al., Health care savings with the patient-centered medical home: community care of North Carolina's experience. Population Health Management, 2014. 17(3): p. 32. 52. Claffey, T.F., et al., Payer-provider collaboration in accountable care reduced use and improved quality in Maine Medicare Advantage plan. Health Aff (Millwood), 2012. 31(9): p. 2074-83. 53. Maeng, D.D., et al., Improving patient experience by transforming primary care: evidence from Geisinger's patient-centered medical homes. Popul Health Manag, 2013. 16(3): p. 157-63.