POP HEALTH PRELIM 2

Healthcare value equation

Value = Quality / Cost; quality includes outcomes and patient experience.

Health disparity

An observed difference in health outcomes between populations.

Health inequity

An unfair, avoidable, and unjust difference in health outcomes.

Health equity

A fair opportunity for everyone to attain their highest level of health.

Equality vs. equity

Equality gives the same resources; equity allocates support according to needs and barriers.

Curb-cut effect

Designing for people facing barriers can benefit the broader population.

Co-design

Developing health interventions with input from affected communities.

Triple Aim

Improve population health and patient experience while lowering per-capita cost.

Traditional Quadruple Aim

Triple Aim plus healthcare workforce well-being.

Equity-centered Quadruple Aim

An approach placing health equity at the center of healthcare improvement.

Quintuple Aim

Population health, patient experience, costs, workforce well-being, and equity.

Structural racism

Policies and institutions that systematically create unequal opportunities and health outcomes.

Race is not a risk factor; racism is

Racialized health differences reflect social and structural exposures, not race as innate biology.

Upstream intervention

Addresses root social, environmental, or policy causes of health problems.

Downstream intervention

Treats health problems or consequences after they arise.

Data disaggregation

Breaking overall statistics into population groups to uncover hidden disparities.

REAL and SOGI data

Demographic data used to examine inequities; SOGI = sexual orientation and gender identity.

PolicyMap

Mapping platform used to visualize geographic patterns in health and social conditions.

Polygon or area data

Data assigned to geographic regions such as census tracts.

Point data

Data representing specific geographic locations such as clinics.

Ecological fallacy

Inferring individual-level relationships from aggregate geographic or group data.

Geographic scale

The size of mapped units; finer units may reveal variation hidden by larger units.

Primary care

First-contact, continuous, comprehensive, coordinated, person-centered healthcare.

First-contact access

Primary care serves as an accessible initial entry point for new health concerns.

Continuity

An ongoing relationship between a patient and their primary care team.

Comprehensiveness

Primary care addresses a broad range of preventive, acute, and chronic needs.

Coordination

Organizing services and communication across providers and care settings.

Person-centeredness

Adapting care to patient goals, values, preferences, and circumstances.

Primary care vs. specialty care

Primary care is generalist and longitudinal; specialty care is condition-focused and often episodic.

Proactive care

Identifying and managing risks before complications or crises develop.

Prevention 1.0

Evidence-based clinical prevention, screening, and counseling.

Prevention 2.0

Screening for and responding to individual health-related social needs.

Prevention 3.0

Addressing upstream structural and community conditions that shape health.

USPSTF

Independent expert panel making evidence-based clinical preventive service recommendations.

USPSTF Grade A

High certainty of substantial net benefit; offer the service.

USPSTF Grade B

Moderate or substantial net benefit with sufficient certainty; offer the service.

USPSTF Grade C

Small net benefit; selectively offer based on patient circumstances.

USPSTF Grade D

No net benefit or harms outweigh benefits; discourage the service.

USPSTF Grade I

Evidence is insufficient to determine the balance of benefits and harms.

ACA and USPSTF A/B

Most qualifying plans cover recommended A/B preventive services without cost-sharing.

Primary care quality gap

Patients receive only about 54% of recommended healthcare services in the cited study.

Physician time estimate

About 18.7 hours/day for preventive, chronic, and acute care for a 2,500-patient panel.

Team-based care

Sharing care responsibilities across appropriately trained healthcare professionals.

Top of license

Team members perform the highest-level work appropriate to their training and scope.

Standing orders

Protocols allowing qualified staff to perform specified services without a new order each time.

Primary care paradox

Primary care delivers many office visits but receives a small share of total spending.

Fee-for-service (FFS)

Payment per service delivered; generally incentivizes volume rather than outcomes.

Low-complexity patients

Patients with relatively limited ongoing care management needs.

Moderate-complexity patients

Patients needing more coordination, often due to multiple manageable chronic conditions.

High-complexity patients

Patients with multiple medical conditions and often significant social or behavioral needs.

Social drivers of health (SDOH)

Social, economic, and environmental conditions that positively or negatively influence health.

Social risk factor

An adverse social condition identified for an individual patient.

Health-related social need (HRSN)

A social risk for which the patient indicates they want assistance.

Social screening autonomy

A positive screen does not automatically mean the patient wants help.

Health Leads approach

Connect patients with social resources alongside clinical treatment.

ICD

International Classification of Diseases; standardized health condition classification.

ICD-10-CM

U.S. coding system for clinical diagnoses and health conditions.

ICD-10-PCS

Coding system for inpatient hospital procedures.

CPT/HCPCS

Coding systems for healthcare procedures and services, often used for billing.

Z codes

ICD-10-CM codes for factors influencing health status and healthcare encounters.

Z55–Z65

Codes for socioeconomic and psychosocial circumstances.

Z59.41

Food insecurity.

Z59.82

Transportation insecurity.

Z59.6

Low income.

Electronic health record (EHR)

Digital patient record integrating medical information and potentially social risk data.

Patient panel management

Using data to monitor and coordinate care for a defined patient population.

PRAPARE

Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences.

CMS five HRSN domains

Food, housing, transportation, utilities, and interpersonal safety.

HRSN screening rate

Number screened for all five domains divided by total eligible adult admissions.

HRSN screen-positive rate

Number with a positive screen divided by number screened.

Closed-loop referral

Referral tracked through follow-up so the care team knows the outcome.

Warm handoff

Personal introduction and supported transition to another provider or service.

Community-based organization (CBO)

External community organization providing resources such as food or housing assistance.

Social care navigation

Helping patients connect with services addressing patient-identified social needs.

Social screening barriers

Time, reimbursement, trust, privacy, language, and referral capacity can limit screening.

Montefiore missed appointments

26.3% overall; 31.5% with ≥1 social need; 36.0% with transportation need.

Wagner Chronic Care Model

Framework for proactive chronic care through systems, teams, information, and community support.

Wagner: self-management support

Equip patients to manage their own chronic conditions.

Wagner: delivery system design

Organize care teams and workflows for effective chronic care.

Wagner: decision support

Embed evidence-based guidelines into clinical decisions.

Wagner: clinical information systems

Use data systems to track patients and coordinate treatment.

Wagner: health system organization

Align leadership and structures to support high-quality chronic care.

Wagner: community resources

Connect patients with supportive services beyond the clinic.

Chronic Care Model desired interaction

An informed, activated patient working with a prepared, proactive care team.

HCHN

High-cost, high-needs patients with complex medical and often social circumstances.

5–50 rule

Roughly 5% of patients account for 50% of healthcare spending.

Healthcare hotspotting

Using data to identify concentrated utilization and needs for targeted intervention.

Risk stratification

Classifying patients by risk of poor outcomes or high healthcare utilization.

Patient segmentation

Grouping patients with similar characteristics and care needs.

Tailored care

Designing services appropriate to particular patient groups or individuals.

Utilization-based stratification

Uses prior ED visits, hospitalizations, or readmissions to identify patients.

Cost-based stratification

Uses prior healthcare spending to identify patient groups.

Disease-based stratification

Uses diagnoses and chronic condition burden to identify patients.

Combined stratification

Uses multiple indicators such as disease, cost, and utilization.

Integrated Practice Unit (IPU)

Multidisciplinary care organized around a condition or defined patient need.

Ambulatory Care Sensitive Condition (ACSC)

Condition for which effective outpatient care may prevent some hospitalizations.

Camden Coalition

Hotspotting program providing intensive care management to patients with repeated admissions.

Camden eligibility example

At least two chronic disease-related hospital admissions within six months.

Real-time patient data

Timely information enabling care teams to intervene rapidly after changes or acute events.

Predictive modeling

Uses patient data to estimate future risk; does not prove an intervention will work.