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Tuesday Feb 28, 2017

AAFP to Help FPs With Population Health

I am taking a brief departure from the Patient Protection and Affordable Care Act, the Medicare Access and CHIP Reauthorization Act and politics, to introduce you to some exciting work the AAFP is doing in population health and the emerging field of social determinants of health (SDoH).  

The AAFP is at the leading edge among physician organizations in exploring ways to incorporate both population health and SDoH into family medicine and primary care practices.

Although both population health and SDoH have been prominent in health services research circles for many years, their relevance or contributions to physician delivery and payment models is just now coming into light. Family physicians have long been aware of the demographic, socio-economic, and family issues that impact their patients. This is at the core of family medicine and the meaningful relationships you have with your patients. However, as delivery and payment models move away from episodic-based methodologies and become more intensely focused on longitudinal care and patient outcomes, the need for a more robust evaluation of patients and their environments has become more relevant and desired.  

I like to summarize this transition as follows: family physicians, under advanced delivery and payment models, will care for the individual but manage a population. In order for family physicians to manage a population, they will need new data and new perspective on their patients.

Family medicine is fortunate to have some of the country's leading experts on these issues contributing to our work both directly and indirectly. I asked two of those experts to help frame what is meant by "population health" and "social determinants of health" and how they contribute to better primary care.

Julie Wood, M.D., MPH is the AAFP's Senior Vice President for Health of the Public and Interprofessional Activities. She is a leading national voice on the policy and practice issues that occur at the primary care level due to the intersection of primary care, public health, and population health. I asked Dr. Wood to define population health and the role it plays in family medicine. Here is her response:

"Population health is a term being more frequently used in both healthcare and public health. The population being considered may vary based on an individual's perspective and goals. For the family physician, the most obvious 'population' is their patient panel. This is where most AAFP members focus their energies and where they often have the greatest impact. Population health also includes the health status and outcomes of the larger communities to which the physician and patient belong. It is essential when caring for patients that family physicians consider the factors beyond the walls of their practice that influence their patients' health. The family physician and their team must consider the social and physical environments in which their patients live and work in order to effectively improve health outcomes."

Andrew Bazemore, M.D., is the Director of the Robert Graham Center and is recognized as one of the leading thinkers on SDoH. I asked Dr. Bazemore to frame what SDoH are and why they are important to family medicine. Here is his response:

“Social determinants of health (SDH) are the milieu of social, economic, occupational, and environmental factors that influence the health of the patients and populations we serve. They impact morbidity and mortality more than anything we traditionally address through clinical care, yet most family physicians aren't given the training or tools to incorporate information about patients' SDoH into healthcare decision-making at the point-of-care."

With a richer understanding of population health and SDoH, the AAFP has been aggressively pursuing tools, resources, and education to assist family physicians incorporates both into their practices. To this end, the AAFP recently launched one of the nation's first population health tools, the Community Health Resource Navigator  (CHRN). 

CHRN,  built by HealthLandscape, is designed to provide family physicians and their teams information at the point-of-care on community resources, such as housing and food options for low-income patients, smoking cessation resources, addiction treatment centers, or family and caregiver support organizations to name a few. By having this information at the point-of-care, physicians and their teams are better positioned to provide comprehensive care to their patients that, hopefully, results in better outcomes for the patient. Under new value-based payment models, better outcomes for patients equates to higher payments for family physicians. 

We are excited about CHRN, but HealthLandscape is actively building a next generation tool called Community Vital Signs (CVS) that will allow physicians and practices to incorporate patient-level data using HealthLandscape's innovative, interoperable, HIPAA-compliant tool, the Geoenrichment Application Programing Interface (API), which aims to connect the patient to the broader community where they live.

The Geocoding API appends a core set of community vital signs to any patient with a valid address. Using patients' addresses from an originating data system, the API geocodes each address, assigning longitude and latitude coordinates. Next, it derives geographic identifiers (e.g., county, census tract) for each coordinate. The API then links available community vital signs with the assigned geographic identifiers. Lastly, it returns the geographic identifiers and community vital signs to the originating system. 

Furthermore, since it uses an API, CVS is designed to work with your existing electronic medical record and its built-in registry functions, thus negating the need to purchase an add-on registry component or module. CVS, once implemented, will provide access to an enhanced set of community resources similar to those in CHRN, but it will also allow for the identification and aggregation of patient level data to assist practices in identifying hotspots in their patient population. In a value-based payment model, the ability to identify high-cost, high-need patients is important to the success of the practice.

In addition to our work to build tools and resources, the Graham Center, through a collaboration with the Health Resources & Services Administration (HRSA) and other partners, is developing population health/SDoH curriculum and tutorials that will assist family physicians and the primary care team in incorporating population health and SDoH into their practices.  This curriculum and associated tutorials will greatly assist family physicians interested in using population health/SDoH tools in their practices.

Wonk Hard
While writing this post, I realized that many of you may not be familiar with HealthLandscape, so I thought I would introduce you. HealthLandscape is an interactive, web-based mapping tool that allows health professionals, policy makers, academic researchers and planners to combine, analyze and display information in ways that promote better understanding of health and the forces that affect it. The tool brings together various sources of health, socio-economic and environmental information in a convenient, central location to help answer questions and improve health and health care.

The AAFP, in partnership with the Greater Cincinnati Health Foundation, co-founded HealthLandscape in 2007. In 2014, the AAFP acquired full ownership of HealthLandscape. If you would like more information on HealthLandscape, please participate in one of its introductory webinars or send an email to info@healthlandscape.org.


Excellent post. I definitely see this as a large part of the future of our specialty.

Posted by Trevor Huber DO on February 28, 2017 at 01:29 PM CST #

This is a very interesting direction that the AAFP has been working on. It has some very great research database potential. But I also believe it does represent an ability to ration or mandate care to the closest resource. It may take the physician recommendation out of the care plan. Our family medicine practice already has a list of the available resources in our immediate as well as more distant areas. Patient plans are individualized and we do not always use the closest resource but attempt to use the most appropriate resource. We also have a group of resources which we would not recommend. So, one of the questions this leads to is: Is this website going to turn into a rating service for the resources also. That sort of thing may work for Hotels.com or Expeida.com but is it the way we should be getting health care resources to our patients?? And do we really want our reimbursement to be coupled to it--remember what patient satisfaction scores did to opioids.

Posted by Peter Lueninghoener MD on February 28, 2017 at 06:02 PM CST #

I feel this is just another burden to my solo practice. I do not have the time,expertise or desire to do the tasks of public health department. Providing evidence based patient centered care should provide good population medicine.
Rather than creating another layer of bureaucracy AAFP should focus on efforts to provide accessible care to every American. That alone would go a long way to improve the population health.
I for one do not wish to be judged or paid based on the health status of the community in which I practice. I think we in medicine are allowing outside forces ( payors) dictate how we practice medicine.
We follow rather than lead.
Who is dictating to the insurance companies, the pharmaceutical companies to control cost. I am tired of wasting my time trying to determine which BP med, which migraine med, which PPI to prescribe based on a formulary that is not based in evidence but in finances. Prior authorizations for tests have increased and now there is a plan that requires prior authorization for referrals to specialists. All this costs me money and does not contribute to population health.
I don't want another report to analyze and give me information that is outdated and inaccurate. I get notices everyday from insurance companies stating pat is not compliant or needs test - at least 50% of the time the information is incorrect. Instead of taking care of patients I am shuffling through paper.
Has Dr Wood practiced real primary care recently?
Please no more reports - promote accessible affordable medical care and population health will be accomplished. Those of us who practice medicine already know the deterrents to good health outcomes. More money is not needed to study it. Invest money in providing accessible affordable care.

Posted by Louise Maloney on March 01, 2017 at 05:44 AM CST #

Thanks Shawn.

Let's hope this is a means to an end, and not the end to all means by what you'd said:

"... better outcomes for patients equates to higher payments for family physicians."

Posted by Michael N., MD on March 08, 2017 at 11:14 AM CST #

I agree with Louise Maloney. I have just started to read these articles and can not believe this is what the AAFP is just focusing on. I read the bio of the author and wonder if he has even practiced in a private office. I have been practicing for 30 years and am dismayed by the poor health care we are providing. Shame on the AAFP. Physicians are too busy trying to punch buttons in the EMR answering questions we are forced to ask and keep data that is never used. There are too many physicians with MBA's, MPH's and hospital administration degrees making policy. Let physicians who are really "In the Trenches" make policy. Who is helping our young physicians want to stay in private practice and not go to urgent cares? Who is helping us make up for the 10-20% lost in productivity since EMR implementation? Has anyone done research on how many lost office visits that created for a "population"? Let's make that the next study to spend money on.

Posted by Sharon Bertroche MD on March 15, 2017 at 01:38 PM CDT #

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About the Author

Shawn Martin, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy.

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The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. All comments are moderated and will be removed if they violate our Terms of Use.