PUBPOL 3280 Prelim #2 flashcards

Healthcare value equation

Value = quality relative to cost. Quality includes health outcomes and patient experience; access also matters.

Health disparity vs. health inequity

A disparity is a difference; an inequity is an unjust, avoidable difference rooted in unfair conditions.

Triple Aim

Improve population health, enhance the care experience, and reduce healthcare costs.

Quadruple Aim

The Triple Aim plus attention to provider and workforce well-being.

Quintuple Aim

Expands the aims to emphasize health equity alongside population health, care experience, costs, and workforce well-being.

“You can’t have quality without equity”

High-quality care must address unfair barriers and inequities, not only clinical outcomes.

Curb-cut effect

Designing for people facing the greatest barriers can benefit everyone.

“Race is not a risk factor. Racism is”

Structural racism and unequal social conditions can produce health inequities; race should not be treated as biological destiny.

Upstream health determinant

A structural or social condition shaping health, such as redlining, housing policy, or poverty.

Downstream health outcome

An outcome closer to the individual, such as diagnosed diabetes prevalence.

Upstream-to-downstream framework

Structural and social conditions influence environments and behaviors, which can contribute to health outcomes.

REAL data

Race, ethnicity, and language data used to identify inequities and improve health equity.

SOGI data

Sexual orientation and gender identity data.

PolicyMap

A mapping tool used to visualize and compare geographic patterns in social, economic, environmental, and health data.

Polygon layer

Area-based geographic data displayed on a map, such as census tracts or ZIP Code Tabulation Areas.

Point data

Data displayed as specific locations, which can be overlaid on shaded geographic areas.

Ecological fallacy

Assuming area-level patterns describe every individual living in that area.

Interpreting area-level maps

Say “areas with higher prevalence” rather than assuming every individual in those areas has the characteristic.

Reliable map comparison

Use consistent map scales and centers, clear legends, and cited data sources and years.

Finished PolicyMap export

Include a title, legend, description, logo, data year, and data source; export the map as a PNG.

Primary care

A community-partnered, first-contact, continuous, comprehensive, coordinated, person-centered approach to health.

Primary care vs. specialty care

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

Five Cs of primary care

First-contact access, continuity, comprehensiveness, coordination, and person-centeredness.

First-contact access

Primary care is the accessible first point of contact for health needs.

Continuity

Ongoing care over time with knowledge of the patient’s history and needs.

Comprehensiveness

Addressing a broad range of health needs rather than one condition alone.

Coordination

Organizing care across clinicians, services, and settings.

Person-centeredness

Care shaped around the individual’s needs, values, preferences, and circumstances.

Benefits of primary care

Better health outcomes, prevention, immunization, counseling, and chronic disease management, with fewer avoidable hospitalizations, nonurgent ED visits, and specialist visits.

Primary care physician supply and health

Higher primary-care physician availability is associated with better outcomes, lower mortality, and longer life expectancy.

Premature mortality statistic

One additional primary care physician was associated with 1.44 fewer premature deaths per 10,000 people.

Prevention 1.0

Clinical prevention, including evidence-based screening, counseling, and preventive medications.

USPSTF

The U.S. Preventive Services Task Force, an expert panel that issues evidence-based preventive-service recommendations.

USPSTF grades

A, B, C, D, and I, with I indicating insufficient evidence.

USPSTF A and B recommendations

Services recommended by the USPSTF that ACA plans generally must cover without cost-sharing.

Colorectal cancer screening

Can identify precancerous polyps so they can be removed before cancer develops.

Limitation of Prevention 1.0

Clinical prevention alone cannot address structural causes of health risks or all barriers that prevent people from accessing care.

Recommended care statistic

The slides report adults receive about 54% of recommended care overall

Primary-care workload estimate

A 2,500-patient panel was estimated to require 18.7 hours per day, excluding administrative work.

Nonmedical factors and health outcomes

The slides attribute 80% of health outcomes to nonmedical factors.

Prevention 2.0

Screening for individual health-related social needs and connecting patients to support and community resources.

ICD-10-CM

The U.S. clinical modification of ICD-10 used to code diagnoses in inpatient and outpatient settings.

ICD-10-PCS

A procedure classification developed by CMS for inpatient hospital procedures.

CPT and HCPCS

Coding systems used to describe procedures and services for billing.

ICD-10-CM vs. ICD-10-PCS

ICD-10-CM codes diagnoses; ICD-10-PCS codes inpatient procedures.

Z codes

ICD-10-CM codes used to document social and psychosocial circumstances that influence health or contact with health services.

Z-code range Z55–Z65

Codes covering socioeconomic and psychosocial circumstances that may affect health.

Z-code implementation in Medicare fee-for-service

The slides identify 2016 as the first implementation year.

When can a Z code be used? As a first-listed or secondary diagnosis when supported by appropriate documentation.

Documentation supporting Z codes

Clinician documentation, including information obtained through patient self-report and social-needs screening.

Z59.41

Lack of adequate food or food insecurity.

Z59.82

Transportation insecurity.

Z59.6

Low income.

Social determinants or drivers of health (SDOH)

Social conditions that positively or negatively influence health and affect everyone.

Social risk factor

A negative social influence on health that is identified through screening or patient interaction.

Health-related social need (HRSN)

A patient-identified need for support or connection to resources.

SDOH vs. social risk factor vs. HRSN

SDOH are the broader social influences; a social risk factor is a negative influence; an HRSN is a specific need the patient identifies.

Principles of social-needs screening

Empathy, respect, autonomy, trust, dignity, and open dialogue.

Potential benefits of screening and follow-through

Improved patient satisfaction, trust, health, quality of life, and potentially healthcare utilization and spending.

Barriers to social-needs screening

Time constraints, limited compensation, and clinician concerns about their role or available resources.

Healthcare hot spotting

Using data to identify high-need, high-cost patient groups and target proactive, tailored care.

HCHN

High-cost, high-needs patients who may benefit from complex care management.

Super-utilizers

A term used to describe patients with particularly high healthcare utilization and often complex medical and social needs.

Why HCHN patients often need complex care

Multiple chronic illnesses may coexist with poverty, substance use disorders, mental health challenges, housing insecurity, and social isolation.

Why fragmented fee-for-service care can fail HCHN patients

Repeated emergency visits and hospitalizations may occur without addressing underlying clinical and social needs.

Super-utilizer statistic

The slides report that approximately 5% of the U.S. population accounts for 50% of healthcare spending.

Preferred language for high-utilizing patients

“HCHN patients” or “super-utilizers” is preferable to stigmatizing labels such as “ED frequent fliers.”

Three core hot-spotting steps

Identify and risk-stratify patients, segment them into similar groups, and tailor teams and services.

Risk stratification

Estimating patient risk to identify who may benefit from different levels of care.

Risk-stratification approaches

Utilization-based, cost-based, disease-based, or combined methods.

Limitation of risk stratification

It is only as good as the data collected.

Integrated Practice Units (IPUs)

Multidisciplinary teams organized around a medical condition or specific patient needs.

Wagner’s Chronic Care Model

A framework for improving chronic disease care through coordinated clinical systems and community support.

Goal of Wagner’s Chronic Care Model

Productive interaction between an informed patient and a prepared care team.

Six elements of Wagner’s Chronic Care Model

Self-management support, delivery system redesign, decision support, clinical information systems, health-system organization, and community resources.

Camden Coalition admission criterion

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

Early reported Camden hot-spotting results

A 40% reduction in ED visits and a 56% decrease in hospital charges.

Later Camden randomized trial

Found no difference in 180-day readmissions but a significant increase in SNAP uptake.

Interpreting hot-spotting research

Readmissions may not capture every meaningful outcome; context, population differences, and intervention design matter.

Ambulatory care-sensitive conditions (ACSCs)

Conditions for which timely, effective outpatient care may prevent hospitalization.

Project ECHO complex-care criteria

Multiple chronic conditions plus recent hospital admissions or repeated ED visits, targeting people who may not be engaged in care.

Sutter Care Coordination criteria

Examples include an unplanned readmission within 30 days, two or more admissions or ED visits in a year, seven or more medications, or multiple chronic conditions.

Why use real-time data in hot spotting? To identify changing patient needs proactively and respond before a crisis leads to ED visits or hospitalization.

Dr. Jeffrey Brenner’s hot-spotting principle

Bringing good care to people can be cheaper and more effective than waiting for them to navigate access on their own.

Why might a patient repeatedly use the ED? Unmet medical and social needs, barriers to primary care, fragmented services, and a lack of trust or support may contribute.

Complex care management (CCM)

Coordinated, tailored care for patients with complex medical and social needs, delivered by multidisciplinary teams.

Essential CCM components

Tailored multidisciplinary teams, comprehensive assessment, coordination with primary care, and proactive information sharing.

Predictive modeling in CCM

Uses risk software, chronic disease criteria, utilization thresholds, referrals, and acute events to identify patients most likely to benefit.

Comprehensive health assessment

Identifies clinical, social, behavioral, and other problems that interventions may address to improve care and reduce expensive services.

Three levels of tailoring complex care

Care context; team tailored to the target population; and care plan tailored to patients’ clinical and social needs.

Tailoring the care context

Consider practice size and type, rural versus urban setting, payment arrangements, and governance.

Tailoring the care team

Match team roles and skills to the population’s clinical, cultural, linguistic, literacy, age, and geographic needs.

Tailoring the care plan

Address the target population’s clinical, social, behavioral, and occupational needs.

Patient-centered question

“What matters to you?” This helps teams understand patient priorities before establishing longer-term goals.

Building trust with patients

Use culturally and linguistically concordant care, warm handoffs, tangible improvements, reliable follow-up, and motivational interviewing.

Motivational interviewing

A supportive approach that evokes a patient’s own reasons and motivation for behavior change through listening and reflection.

Home visits

Reveal real-life barriers, medication issues, food patterns, and home conditions affecting health.

“Refrigerator biopsy”

Observing food availability and feeding patterns in the home to understand a patient’s circumstances.

Medication nonadherence

Not taking medications as prescribed, often because of practical barriers, cost, side effects, or other challenges.

Medication nonadherence statistic

The slides report that about 50% of Americans do not take chronic long-term medications as prescribed.