HPA 311

The Healthy People (https://www.healthypeople.gov/ (Links to an external site.)) initiative is one of the largest of these initiatives—it provides

objectives for the next 10 years for individuals and organizations to use to inform their health and intervention decisions.

There can often be a large (sometimes deliberate) discrepancy between

policy as intent (what is planned, stated or written) and policy as practice (what actually happens).

Less research is done about differences in health by religious group, but some studies have shown that the discrimination felt by Muslims in a post 9/11 society has resulted in their deteriorating health status:

-Above average rates of anxiety; -Fear of hate crimes; -Increased experiences with trauma

Some of the major Operating Divisions of HHS include:

-Agency for Healthcare Research and Quality (AHRQ) -Centers for Disease Control and Prevention (CDC) -Centers for Medicare & Medicaid Services (CMS) -Food and Drug Administration (FDA) -Health Resources and Services Administration (HRSA) -Indian Health Service (IHS) -National Institutes of Health (NIH)

-More than ______% of individuals in the U.S.(more than 60 million people) speak a language other than English at home. -__________ percent do not speak English at all. -An additional ______% of individuals reported not speaking English well.

20% 7% 15%

Individual:

While we are all individuals, we are also part of a family and society. How we experience a health determinant, or make individual-level decisions is influenced by factors we experienced in our family, as well as those that are in the larger society. For example, while our highest level of education is highly influenced by our own individual-level of intelligence and desire to stay in school, our parents' level of education, and perhaps their social network also influenced your educational opportunities.

The U.S. Department of Health & Human Services summarizes the key features of this law as:

Coverage Costs Care

__________ ___________ are more likely to have a chronic health condition, which means they need to see a healthcare provider more often.

Older Adults

Public Health

Public Health is a framework for implementing interventions to address the health of communities. While many of the concepts we discuss in population health are identical to those in public health, particularly the determinants of health, the two fields are distinct by the intervention - or action - that is central to the field of public health. For example, a public health intervention to address high rates of dental cavities in a population may be to add fluoride to the water supply.

Religion

Religion is a cultural belief of views, behaviors and practices that some individuals and cultural groups follow as a guide for the purpose and order of our existence.

Society:

Society is filled with individuals that can also be grouped into families.

Need for primary care providers

Specifically, there is a need for primary care physicians who spend the majority of their time providing direct patient care. Currently, fewer than one third of physicians are primary care, or family practitioners, and these are the physicians who are most focused on preventive care. More physicians who are primary care providers are necessary to train the next generation of physicians as well, and to emphasize their important role in improving overall population health.

Structural:

The complex systems and structures that influence social, environmental and behavioral determinants of health (e.g. residential racial segregation).

Behavioral:

The decisions and actions by individuals that affect their health (e.g. diet, exercise, smoking, etc.); these determinants can influence biological determinants;

Social:

The economic and social conditions that influence group differences (e.g. race, education, income);

Other National Health Policies

While the Affordable Care Act is certainly the largest health policy in the U.S., there are a number of other national health initiatives in progress.

Standards were developed by the U.S. Department of Health and Human Services Office of Minority Health to provide

a framework to health care organizations called the National Standards for Culturally and Linguistically Appropriate Services in health and health care, or CLAS Standards.

Because members of Congress represent geographic constituencies that have elected them to their posts, they may

advocate for specific interests that benefit the people who they represent.

Disability patterns are largely driven by ______, with 25% of adults aged 45-64, and 35% of adults aged 65 and older.

age

While our diversity should be celebrated, unfortunately some populations experience differences, or inequalities, in health outcomes or quality of care because of how

an individual is treated due to their particular individual characteristics.

Health Disparities

are the unequal difference in health outcomes and services that exist among vulnerable population groups, whether they be by age, race, ethnicity, education, income, geography, disability, or sexual orientation.

Prior to the Affordable Care Act, uninsured smokers were less likely to

be advised to quit smoking by their doctor; now, since the goal is for everyone to have health insurance, and because smoking cessation is required as coverage, you would expect to see a decrease in smoking rates.

The goal of some of these initiatives is to provide

benchmarks, or goals, for our health, and like the Affordable Care Act, influence determinants and their association with population health outcomes and patterns.

In many large national datasets, Hispanic ethnicity has largely been the major group collected alongside the largest racial groups of Asian, Black, and White, but Hispanics

can be of any race

Intersections between race and gender, with considerations for age, are the most ______________ way diverse groups are examined in population health.

common

However, agreement on the approach to these challenges, and the amount of funding that should be dedicated to each approach must be agreed upon by

congress

However, federal spending largely influences the future electability of members of

congress

As indicated in the article, behavioral economics is different from its larger parent discipline economics, in that it

considers the alternative to economics' assumption that human beings make rational decisions, accepting that humans do not always do what is the rational, expected behavior.

Looking at our policy determinants and outcomes diagram below, we see how the Affordable Care Act directly influences determinants and the association between

determinants and population health outcomes and patterns, such as rates of smoking.

Related to healthcare, the income: poverty ratio is quite important, particularly as related to health-related policy, because they inform the federal poverty level (FPL) guidelines, which is the _______________ _______ __________ needed by families for basic necessities such as food, shelter, and clothing.

determined gross income

Social determinants include a combination of

education, employment, income, family and social support, and community safety.

Aging patterns are largely driven by

ethnic/racial minorities;

Behavioral economics first started in

finance

Our health as individuals and communities is determined by a complex combination of interrelated factors as large as the environment, and as individual as our genetics, income, education and relationships with friends and family. These factors are called

health determinants.

As mandated by law, HHS must update its strategic plan, which describes

how it will address our countries unique population health challenges.

The Patient Protection and Affordable Care Act's goal is to

increase access to health services, and improve healthcare coordination and reduce the cost of healthcare.

Health determinants also happen across the multiple levels of our lives -

individual, family/community, and society.

The Affordable Care Act, a public policy, was designed to

influence many health determinants.

Socioeconomic status

is the social standing of a group or individual, generally measured through combinations of education, income, occupation or wealth.

government plays a _______ role in health policy.

large

Policies are written as

laws, as documents, as procedures, guiding principles, or as statements of intent or frameworks.

As we discussed, health determinants and the different levels of these determinants interact together to become

more complex health determinants and health services outcomes, particularly as you see how population health is applied in health services.

They get developed and implemented through

negotiation, repeated practice, or through legal actions such as orders or decrees.

As the bar graph shows above, the infant mortality rate of Black or African American populations is the highest, or worst, infant mortality rate, and is more than two times higher than the________ population. The ____________ population has the lowest, or best, infant mortality rate.

non hispanic white population Asian and Pacific Islander

In research, when we talk about outcomes, we often describe populations on average. Unfortunately, when trying to improve the overall health of a population on average, this may mean that

not all populations improve their health equally.

Additionally, the World Health Organization's framework for action on interprofessional education and collaborative practice was created to provide

policymakers with strategies and ideas to encourage interprofessional education and collaborative practice, where students from different professions learn together and in collaboration with each other.

To accomplish this, the healthcare delivery system must transition from one that is focused on individual-level healthcare delivery to one that carefully examines _______________ ____________ ______________, particularly health patterns of the most vulnerable.

population health patterns

The needs in health professions education have changed as a result of changes in

population health patterns.

Balancing these three aims, particularly costs, across health determinants and populations is a challenge. However, care, health and cost are all highly relevant for

population health, and why it is a growing field.

The age distribution of a country is often depicted in _______________ ________________, a commonly used infographic used in population health that shows the percent of the population by respective age categories.

population pyramids

The goal in interprofessional education is to

prepare future healthcare professionals for interprofessional care of patients using a population health approach.

The primary challenge in achieving these aims is

reaching a balance across the three areas.

Ethnicity is also a

social construct and refers to a common language, ancestry cultural or historical experiences within groups of populations.

Race is a

social construct primarily used in the U.S. to group people together, largely on phenotype, or what an individual looks like or the color of his or her skin. It has no biological meaning.

_________ ___________ are the most important determinants when predicting our health

social determinants Even factors such as smoking and health services and access have less of an impact on health.

Biological:

Individual-level genetics and physiological systems and processes; these determinants can also influence our behaviors;

These negative experiences can become ________________ and are reflected in poorer health patterns for some populations, largely through socioeconomic status and how that gives many individuals access to sources of healthcare.

"embodied"

In response to the "triple aim", common terms you hear in healthcare are

"population health management" and "population medicine". When you see these terms, know that they are referring to population health in a clinical setting.

Prochaska's transtheoretical model of behavior change, often referred to as the because of the six stages people progress through in reaching that change:

"stages of change"

The U.S. Department of Health and Human Services (HHS) is

"the principal Federal department charged with protecting the health of all Americans and providing essential human services" and has a discretionary budget of >$82 Billion dollars.

So many determinants influence population health that it may feel overwhelming to try and identify a single policy that would address all determinants and the unique population patterns of each health outcome. This is why policies exist in multiple environments (_____________, ________, ____________) and contexts (__________, ______________, ____________, _____________).

(government, city, county) (social, economic, political, cultural).

Care

-Covers Preventive Care at No Cost to You: You may be eligible for recommended preventive health services. (Links to an external site.) No copayment. -Protects Your Choice of Doctors: Choose the primary care doctor you want (Links to an external site.)from your plan's network. -Removes Insurance Company Barriers to Emergency Services: You can seek emergency care at a hospital outside of your health plan's network.

The Gay & Lesbian Medical Association has provided guidelines for the care of special gender-based populations, which include:

-Create a welcoming clinic environment; -Learn the language that patients use to self-identify themselves; -Require staff sensitivity and training around gender issues; -Recognize there is diversity within gender identification groups; -Consider the unique health needs or history of this vulnerable population.

Specific to health professions education, Healthy People 2020 has these objectives:

-ECBP-12-18: Increase the inclusion of core clinical prevention and population health content in M.D.- ,D.O.- and PharmD-granting medical schools, undergraduate nursing, and nurse practitioner and physician assistant training; -ECBP-19: Increase the proportion of academic institutions with health professions education programs whose prevention curricula include interprofessional educational experiences.

Costs

-Ends Lifetime Limits on Coverage: Lifetime limits on most benefits are banned for all new health insurance plans. (Links to an external site.) -Reviews Premium Increases: Insurance companies must now publicly justify any unreasonable rate hikes. -Helps You Get the Most from Your Premium Dollars: Your premium dollars must be spent primarily on health care - not administrative costs.

Coverage

-Ends Pre-Existing Condition Exclusions for Children: Health plans can no longer limit or deny benefits to children under 19 due to a pre-existing condition. -Keeps Young Adults Covered: If you are under 26, you may be eligible to be covered under your parent's health plan (Links to an external site.). -Ends Arbitrary Withdrawals of Insurance Coverage: Insurers can no longer cancel your coverage (Links to an external site.) just because you made an honest mistake. -Guarantees Your Right to Appeal: You now have the right to ask that your plan reconsider its denial of payment. (Links to an external site.)

Some unique gender-based population needs that we see in healthcare patterns include:

-Females on average have a 5-year longer life expectancy compared to males, and males lead in all top 10 leading killers except for Alzheimer's disease. --Explanations for these differences have explored biological (e.g. hormones, metabolism), social (e.g. social support, stress), and behavioral factors (e.g. risky behaviors, diet and exercise). -Gay, bisexual and transgender men and lesbian, bisexual and transgender women smoke at higher rates than other men and women. -Lesbians have lower rates of insurance than heterosexual women.

Creating policy can be a puzzling experience because sometimes multiple parties and levels of government can be involved in the process. However, the basic steps are:

-Identify a problem (e.g. smoking) -Set an agenda (e.g. increase participation in smoking cessation programs) -Formulate policy (e.g. require health insurance plans to pay for smoking cessation) -Implement policy (e.g. pass a law requiring health insurance plans to pay for smoking cessation) -Enforce policy (e.g. penalize health insurance plans that do not pay for smoking cessation) -Repeat the process as necessary

However, we might expect to see some population patterns based on who will remain uninsured. For example:

-In 2014, 32 million Americans remained uninsured; -2.9 million of these uninsured adults live in non-Medicaid expansion states and would qualify for Medicaid and have access to free smoking cessation treatments if they lived in a Medicaid expansion state. -This short example illustrates how one part of a large healthcare policy can influence health determinants and the population health outcomes and patterns that we may observe.

As you can see in the poverty guidelines, FPL is based on family size and income. The FPL then determines federal and state aid options:

-Individuals and families who make <138% of the FPL, depending on your state, may qualify for Medicaid or CHIP -Incomes between 100-400% of FPL may qualify for healthcare tax credits -Families earning between 100-150% of the FPL may qualify for the Supplemental Nutrition Assistance Program (SNAP), which you may know as "food stamps", or Temporary Assistance for Needy Families (TANF), a government benefit many refer to as "welfare."

In the United States, unique language-based barriers in healthcare that non-English speaking patients face include:

-Lower rates of having a usual source of care and preventive services; -Increased non-adherence to medication and leaving hospitals against medical advice; -Lower rates of follow-up care.

individuals living with a disability have unique population needs that influence observable differences in healthcare:

-Lower rates of receiving necessary dental, health care, and health services such as cancer screening; -Lower rates of physical activity (and therefore higher rates of overweight); -Experience more psychological distress and less social support

Some of the unique health needs for older adults are acknowledged in the Centers for Disease Control and Prevention's Call for Action to:

-Promote detection and diagnosis of dementia -Consider dementia in emergency preparedness plans -Increase monitoring of physical activity frequency -Monitor shingles vaccine rates

The top five languages spoken other than English are:

-Spanish -Chinese -French, -Tagalog -Vietnamese.

However, the term policy can have a wide range of different meanings. Policy can be a(n):

-Way of working -Vision -Program of action, duties, responsibilities or accountability -Unwritten cultural or ethical code.

-Gender identification refers to an -Transgender is a term used when -Gender Expression is

-individual's own self-identification. -an individual's own self-identification is different from the biological sex they were born with. -the way an individual presents themselves publicly.

The three aims that should be simultaneously addressed answer these three questions:

1. Care - How do we improve the experience of care? 2. Health - How do we improve the health of populations? 3. Cost - How do we reduce the costs of healthcare?

The Five Lenses of Population Health

1. Demography 2. Public health 3. Health policy 4. Care management 5. Quality and safety

To meet this goal, the Advisory Committee on Interdisciplinary Community-Based Linkages provided recommendations for professional health education to the Secretary of Health and Human Services and to Congress:

1. Faculty in health professions schools and continuing education programs should implement curricula that equip future and current health professionals with the knowledge, skills and tools to understand and efficiently address the health needs of populations by using an interprofessional team approach. 2. Accreditation standards should require health profession programs and schools to integrate significant population health content and interprofessional population health practice into basic curriculum. 3. Licensing bodies should include questions in their examinations that measure understanding of population health and future health professionals' understanding of population health and integration of population health strategies into practice. 4. The U.S. Department of Health and Human Services Health Resources and Services Administration (HRSA) should create funding opportunity announcements that encourages the inclusion of a population health focus in the curricula of health professions education programs, and include teaching and clinical learning experiences with a focus on interprofessional competencies. 5. A national clearinghouse to support resources for population-health related educational resources that can be used for health professionals, public health and other degree and continuing education programs should be created.

Across all ages, nearly _____ % of individuals live with either a hearing, visual, cognitive, ambulatory, self-care or independent living disability. ___________ percent of adults live with a disability.

13% 20%

In the United States,__________% of the population identifies as Christian, ________% are unaffiliated, nearly 2% are Jewish, with approximately 1% each respectively being Buddhist, Muslim, Hindu, and 2% folk or other religions.

70% 23%

These differences in characteristics make up the dimensions of diversity:

Age Disability Gender and sexual orientation Language Race and ethnicity Religion Socioeconomic status

Family:

Families consist of groups of individuals, and are also part of society.

The many different health determinants can be divided into five broad categories as follows:

Behavioral Biological Environmental Social Structural

What is Policy?

Broadly speaking, a policy is a principle or a plan to guide decisions, actions and outcomes.

Care management

Care management is a focus on meeting individual-level health needs through a collaborative planning process with skilled providers. Coordination across these stakeholders and settings is key to successful management of all health outcomes. For example, a number of stakeholders play a role in managing care - the patient and their families, the healthcare provider, the larger health plan and system, and the policy context guiding the roles of each of those stakeholders. Care management seeks to collaborate with these groups to make informed healthcare decisions.

Worldwide, the largest religious practice is _____________, followed by Islam and individuals unaffiliated with a religion.

Christianity

Demography

Demography is the study of describing characteristics of populations, most often issues related to mortality, aging, fertility, and migration. For example, demographers who study health outcomes are often referred to as population health researchers.

Challenges and Barriers to a Population Health Approach to Education

Diversity Need for primary care providers Teaching informatics Increasing Education in Applied Settings

Socioeconomic factors, such as _____________and _____________, affect health the most, at 40%.

Education income

Quality and safety

Errors in the healthcare system can be costly to a patient's health. Quality and Safety is a focus on identifying and rectifying the healthcare delivery process. For example, quality and safety includes the systems in place that systematically examine the processes, structures, and organization of healthcare and actively identify solutions to errors are focused on quality and safety.

Health policy

Health Policy includes the principles or plans to guide decisions, actions and outcomes as they relate to health. For example, the highly descriptive nature of population health makes it very relevant to be used in framing much of health policy, specifically because you learn so much about populations. And health policy is a part of demography, and supports care management, quality and safety, and public health.

Teaching Informatics

Health information systems and the data collected through them, together called informatics, can be an important tool for tracking population health trends within and across healthcare systems. However, there are many informatics systems that exist, and understanding how to use the information collected for the benefit of patient health can be difficult. Therefore inclusion of this important tool in health education programs is important in maximizing its use.

When disaggregating populations by racial and ethnic groups, we often see some of our largest differences in health and health services outcomes:

Hispanics and American Indians/Alaskan Natives have the lowest rates of health coverage

Environmental:

Includes natural (e.g. weather), social (e.g. our neighborhood home values) and built (e.g. safe roads to drive on) conditions external to our human bodies.

Signed into law on

March 23, 2010 by President Obama, the 111th Congress passed Public Law 111-148 [H.R. 3590], the Patient Protection and Affordable Care Act (ACA), also known widely as Obamacare.

behavioral economists focus on

the psychosocial and behavior influences on the decisions of people and institutions when making decisions about the production, distribution and consumption of goods and services.

sexual orientation

the sex of who an individual is sexually or romantically attracted to.

Specifically, as part of the Affordable Care Act,

tobacco cessation must be provided to all individuals at no cost; substance use disorders must be provided as part of mental health coverage; and worksite wellness rewards/penalties for healthy/unhealthy behaviors are guided by federal rules.

The leading cause of death for our youngest group is unintentional injuries - it's not even in the list of top 5 for those aged 65 and older.

unintentional injuries

The differences of opinions on what to prioritize with the government's budget is

what drives the majority of our political discourse.

It is an example of

what will likely be the largest policy specifically directed at health that will be implemented in our generation's time.

Example

when comparing infant mortality rate, a major health indicator for populations, across populations of the United States, you see that the non-Hispanic black infant mortality rate is still nearly double that of the non-Hispanic white infant mortality rate.

Social determinants determine

where we live and work, and where our children go to school and play.

As shown above, from 1980 until 2014 _____________ _______________ consistently had the highest life expectancy, followed by Black females, then White males with Black male life expectancy lagging significantly below all other groups.

white females

African Americans or Blacks report the ___________ overall health.

worst

On average, individuals with lower socioeconomic status (e.g. low levels of education, poor, unemployed or without any wealth) have the ________ health outcomes.

worst