Population Health Management Dashboard POPULATION –> TALLAHASSEE FLORIDA Scenario You have assessed your local population health needs and identified d

Population Health Management Dashboard POPULATION –> TALLAHASSEE FLORIDA

Scenario

You have assessed your local population health needs and identified d

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 POPULATION –> TALLAHASSEE FLORIDA 

Scenario

You have assessed your local population health needs and identified data sources and data sets that are needed to help providers make immediate gains in patient outcomes. Your health systems Board of Directors is requesting that you develop a high-level population health management program dashboard.

For this assessment, you need to assess local population health needs and identify data sources and data sets that are needed to help providers make immediate gains in patient outcomes. It is a major undertaking to plan, design, and implement a robust PHM. Therefore, your health systems Board of Directors is requesting that you develop 1-2 page high-level population health management program dashboard. In this dashboard, list the health needs based on the community needs assessment and the critical data sources and data sets needed for the population health management program your health system is planning to launch.

Instructions

Using the information from the modules 01, 02, and 03 summative assessments, construct a dashboard that lists the health needs based on the community needs assessment that was performed and the critical data sources and data sets needed for the population health management program your health system is planning to launch.

USE THE FILES ATTACHED AS RESOURCES FOR HOW TO CREATE A DASH BOARD

TALLAHASSEE, FLORIDA; Community Needs Assessment
Whitney Gibson

Healthcare Profile

Population 197,787 according to census in 2020

Lack diversity and proper representation.

Low income

Education attainment

People who are well educated are able to receive better healthcare and those with poor education attainment lacking proper healthcare leading to poor lifestyle and mortality.

The addition of vulnerable groups within Tallahassee makes it hard engage in community healthcare program with some vulnerable without having proper medical history and some hiding in fear of deportation documentation.

Majority of healthcare system lack diversity and proper representation.

Low income makes it hard to afford healthcare and coming up with better affordable care might be the solution.

Education attainment is a problem with many teenagers dropping out of schools and engaging in unruly behaviors.

People who are well educated are able to receive better healthcare and those with poor education attainment lacking proper healthcare leading to poor lifestyle and mortality.

The addition of vulnerable groups within Tallahassee makes it hard engage in community healthcare program with some vulnerable without having proper medical history and some hiding in fear of deportation documentation.

Socioeconomic determinants speaker notes

Race related barrier to health.

Low income population.

Access to job.

Education attainment.

Additional vulnerable population (Fuller et al,. 2020).

2

Health and medical resources

Healthcare monetarization.

Healthcare investigation.

Healthcare advocacy.

mobilizing community for safety awareness.

Law enforcement.

Accountability .

Healthcare accessibility.

Healthcare research advocacy

Monitor health status to identify and solve community health problems.

Diagnose and investigate health problems and health hazards in the community.

Inform, educate, and empower people about health issues.

Mobilize community partnerships and action to identify and solve health problems.

Develop policies and plans that support individual and community health efforts.

Enforce laws and regulations that protect health and ensure safety.

Link people to needed personal health services and assure the provision of health care when otherwise unavailable.

Assure competent public and personal health care workforce.

Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

Research for new insights and innovative solutions to health problems.

3

Top Healthcare Needs, Issues & Factors

Growing number of people within the area have an acute health issues within the community that need immediate attention.

The health disparity within Tallahassee are preventable with inclusion of different races being a major problem.

Better and equipped physician that are equipped to handle patients of all care are needed.

Not everyone within Tallahassee is capable of affording healthcare and thus a solution of having affordable healthcare should be discussed.

Technology advancement within healthcare minizes work load at the facility and physician can more patients.

Violence as a result of insecurity and racial profiling within Tallahassee due to lack of proper representation among people of color (Charness et al,. 2019)

Tallahassee, Florida health issues

Chronic diseases and Obesity. Lack of proper health counsel

Health disparities.

Violence within the community.

Behavioral care.

Access to healthcare. Not everyone is able to access care.

Technology advancement in healthcare .

4

Resources needed for progress

Establishment of more healthcare facilities.

Physical capital

Consumables

Investments on medic and Medicaid.

Security patrol

Human resources- healthcare physicians

The establishment of more healthcare system will help mitigate the growing number within the Tallahassee.

Investment and physical capital can help get more medics and Medicaid to the people.

Insecurity within any community is a health disaster that need to get mitigated for the people to feel safe.

Hiring more physicians and getting modern equipment is a hindrance that need to get solved.

5

Key performance indicators

Continuum

Data collected cleansed and normalization.

Risk Stratification. Actionable insights.

Actionable insight.

Patient engagement

1. Capturing as much relevant data as feasible is the first step to effectively manage populations. The challenge that providers often face is that they must analyze their own clinical data from EHRs separately from claims because many enterprise data warehouse (EDW) platforms only allow organizations to analyze claims without the more timely and complete EHR data. Analyzing both data sources together is crucial for a holistic patient view.

2. Once the comprehensive data is captured, it must be cleansed and normalized to ensure the information can be utilized for accurate and reliable guidance about care gaps. An advanced EDW should manage probabilistic patient matching and provide similar matching algorithms for entities such as providers, locations, and hospitals.

3. With data combined, cleansed, normalized and analyzed, organizations must be able to risk stratify patients and deliver prioritized lists to care managers so they can conduct outreach and engage patients in their care.

4. Actionable insights. All these powerful data analytical tools will not help care managers if clinicians cannot understand the reporting or if they are required to search results for actionable insight. Any PHM technology designed to support these care managers, as well as providers, must present easily interpreted dashboards. 

5. Patient engagement. With clearly presented insight and actionable tasks based on care gaps and trends in utilization/cost, care managers can begin conducting outreach using multiple communication methods based on patient preferences. More advanced PHM tools can help reduce care managers’ workload by automating the outreach process via text, phone, or secured email. Outreach efforts engage patients in their care and help them better manage their multiple chronic conditions, which can increase the organization’s fee-for-service revenue, as well as satisfy quality measures for value-based payment contracts

6

Conclusion

The community assessment program help with the establishment of for a program or interventions.

Help with selecting effective strategies to use within the intervention or the program.

The community assessment program helps establish a baseline for the evaluation progress within the given community new strategies and ideas.

The assessment program also helps with the provision of better healthcare for the people.

The work of the community assessment is to identify factors affecting healthcare within said community.

Finding of business needs that needs to get resolved for better results.

Using the community assessment program the people of Tallahassee are able to mitigate their healthcare crisis (Agarwal et al,. 2018.

Reference

Charness, N. H., & Beach, S. R. (2019). DESIGNING TECHNOLOGY TO SUPPORT HEALTHCARE FOR AGING ADULTS. Innovation in Aging, 3(Supplement_1), S31-S32.

Fuller, K., Gravlee, C. C., McCarty, C., Mitchell, M. M., & Mulligan, C. J. (2020). Financial strain and stressful social environment drive depressive symptoms, while FKBP5 variant intensifies the effect, in African Americans living in Tallahassee. bioRxiv.

Dickerson, D., Baldwin, J. A., Belcourt, A., Belone, L., Gittelsohn, J., Kaholokula, J. K. A., … & Wallerstein, N. (2020). Encompassing cultural contexts within scientific research methodologies in the development of health promotion interventions. Prevention Science, 21(1), 33-42.

Jha, A. K. (2019). Population health management: saving lives and saving money?. Jama, 322(5), 390-391.

Agarwal, G., Angeles, R., Pirrie, M., McLeod, B., Marzanek, F., Parascandalo, J., & Thabane, L. (2018). Evaluation of a community paramedicine health promotion and lifestyle risk assessment program for older adults who live in social housing: a cluster randomized trial. Cmaj, 190(21), E638-E647.

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