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.
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 firstname.lastname@example.org.
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