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The American Journal of Accountable Care September 2018
Improving Population Health Through Multistakeholder Partnerships
Nicole Sweeney, BA; Sarika Aggarwal, MD, MHCM; Peter Aran, MD; Deb Dahl, MBA; Joseph Manganelli, PharmD, MPA; Steven Peskin, MD, MBA; Emily Allinder Scott, MHA; David Parker, PhD; Joseph Conoshenti, RPh, MBA; and Anupam B. Jena, MD, PhD
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A Model for Delivering Population Health Across the Care Continuum
Sanjula Jain, PhD; Adam S. Wilk, PhD; Kenneth E. Thorpe, PhD; and S. Patrick Hammond, MHA
“Lean” Improvement in the Quality of Patient Care in the Hospital Admissions Process
Patricia Bonachela Solás, BSc; José Bernabéu-Wittel, MD; M. Nieves Romero Rodríguez, MD; Antonio Castro Torres, MD; and Diego Núñez García, MD
Patient Complexity Characteristics in the Hospital Setting
Baptiste Crelier, MMed; Sven Streit, MD; and Jacques D. Donzé, MD, MSc
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Effectiveness of Enhanced Primary Care on Preventive Health Services
Sarah L. Goff, MD; Lorna Murphy, MA, MPH; Alexander Knee, MS; Haley Guhn-Knight, BS; Audrey Guhn, MD; and Peter K. Lindenauer, MD, MSc

A Model for Delivering Population Health Across the Care Continuum

Sanjula Jain, PhD; Adam S. Wilk, PhD; Kenneth E. Thorpe, PhD; and S. Patrick Hammond, MHA
The Population Health Care Delivery Model presents delivery systems with a framework for developing, piloting, and implementing population health programs across the continuum of care.
ABSTRACT

Objectives: While most payers have been slow to embrace models that would incentivize value-based care delivery, providers have a unique opportunity to take the lead in this endeavor. We examine best practices to develop a Population Health Care Delivery Model (PHCDM) to guide delivery systems as they design and pilot population health programs across the continuum of patient care and to facilitate their coordination with individual clinicians.

Study Design: Systematic review.

Methods: A systematic review of observational studies and health system case studies was conducted. We examined the effectiveness of population health–oriented programs and specific quality improvement initiatives in improving the health outcomes of patient populations across the continuum of care. Our assessment was primarily focused on the structural and design features of successful programs.

Results: We find that population health improvement is a result of (1) prevention and well care and (2) disease management initiatives that are both patient-centered and population-oriented in structure. We identified differences in care delivery objectives as the severity of disease increases across the patient care continuum. The corresponding PHCDM presents a framework for providers to systematically pilot and evaluate population healthcare programs.

Conclusions: The delivery system–clinician partnership is essential to coordinating evidence-based practices across the care continuum and, as a result, strengthening relationships with payers to further incentivize population healthcare delivery.

Am J Accountable Care. 2018;9(3):16-22

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