Fluent Essays

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.  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.  Rubric: - Executive dashboard lists the health needs based on the community needs assessment and the critical data sources and data sets needed for the population health management program with minimal errors or information missing.  - All required graphs are present and are an accurate depiction of the data.  - Executive dashboard is professional in appearance with accurate graphs, figures, charts, and/or images to further explain the data. Deliverable 3: Locating Data Sources and Sets for Population Health Management Brandy Felicita Rasmussen University Population Health Dr. Merle Point-Johnson Deliverable 3 Submitted August 1, 2021 Cardiovascular diseases remain one of the leading causes of death in Florida state and the whole of the United States. Big data present a broader basis within which it is possible to build change while maintaining a unique basis for change and improved change. Cardiovascular diseases (CVDs) have a detrimental impact on the functionality of the heart. The common types include arrhythmias, Marfan syndrome, congenital disease, coronary heart disease, which involve shrinking of the arterial walls, deep vein thrombosis (DVT), heart attack, and heart failure (Adhikari et al., 2018). According to World Health Organization, cardiovascular diseases are a leading cause of death globally, with more people dying annually from CVDs than from any other cause. In 2016, it was estimated that 17.9 million people died from CVDs, equivalent to 31\% of all global deaths (WHO, 2017). Big data sources are crucial in shaping the level of care within a given setting. The major sources of big data include hospital records, medical records, disease registries, and vital records. Each of these data sources helps identify a specific factor that can improve the quality of care based on the underlying health concern. Medical records are essential in help track events as well as transactions between patients and healthcare providers. This information is crucial in understanding the disease history, underlying trends in healthcare use, and specific patient characteristics. Health statistics are crucial and aid in emphasizing change and focusing on the underlying level of healthcare development. Data elements in care delivery present a broader basis for change where it is possible to build change and diversify healthcare quality. Therefore, there are specific elements that need to be assessed effectively within each of the underlying problems. Therefore, the specific data elements essential in this case include new diagnosis, mortality, recoveries, and management approaches. These data elements are crucial in helping build a strong change platform that will improve efficiency and level of change. Mortality data source present an understanding of all deaths while also identifying the proportion of patients who died because of cardiovascular diseases. This is imperative in helping shape individual understanding and key processes that influence change and promote improved commitment to reduce the number of deaths associated with cardiovascular diseases. Recoveries is also a key source of data since it highlights the proportion of patients who have recovered from cardiovascular diseases. This presents a broader emphasis on important processes that define change and promote improved level of management. Critical understanding of these elements will inform the different approaches that shape future initiatives. Most cardiovascular diseases may be prevented by avoiding risk factors such as tobacco use, unhealthy diet, obesity, lack of physical activity, and harmful alcohol use and other substances. Persons with cardiovascular disease or at high risk need early detection and management using counseling and medicines, as appropriate (WHO, 2015). The essential factors that must be effectively controlled due to their role in developing CVD include a family history of CVD, older age, being male gender, smoking, high cholesterol level, alcohol use, and low intake of fruits and vegetables. In addition, the wellbeing of a CVD patient is regulated in vast guidelines that define diet, exercise, and mental wellbeing. Higher adherence to these guidelines improves the health and wellbeing of patients. However, this knowledge on these lifestyle modifications is lacking (Ishihara, 2017). Data forms an integral aspect in the current decision-making and the ability to build change and transform change. Data allows clear decision-making and the ability to improve the level of care. However, it is essential to ensure that accurate data sources are identified to improve the quality of healthcare delivered. Interpreting data is a fundamental element that helps in making accurate decisions. Inability to use data collected means that there is a major deficiency in care delivery. Each data element is defined and interpreted differently based on how it is being understood. This means that learning how to interpret the available data help understand the complex structures and specific characteristics that define a given population. Thus, in effectively understanding the context within which it is vital to improving the healthcare needs of individuals within the local community, it is essential to investigate hospitalization data and determine the number of patients admitted due to cardiovascular diseases (Svačina, 2020). The local statistics collected can also help in making accurate decisions based on the underlying issues. It is imperative to focus on defining a more effective system that defines the improved level of outcome. Monitoring the quality of care and the wellbeing of patients offers a clearer and favourable approach which can be undertaken to improve the health outcomes of the local population. Wellness programs are also a crucial component in improving individual lifestyles. Lifestyle adjustment is crucial for CVD patients considering that they live a highly restricted life concerning what they can accomplish independently. There are major limitations that must be effectively evaluated to attain the needed level of care (Knowles et al., 2019). Dietary intake limits, exercising, and stress reduction form a strong basis within which it is easier to build an improved quality of life among patients. Cardiovascular disease patients are restricted from a high salt diet, processed foods which can have negative implications such as obesity leading to constricted veins stenosis, stroke, and heart attack (Schweda & Krauss, 2020). Exercising is essential, considering that it strengthens the heart muscles and improves health outcomes. References Adhikari, KP, S., & S, A. (2018). Cardiovascular Diseases (CVDs) Risk Attitude and Knowledge Level of Major Risk Factors for Cardiovascular Diseases among 15-19 Years Eleventh and Twelfth-Grade Students of Lekhnath Municipality. Journal of Community Medicine & Health Education. https://doi.org/10.4172/2161-0711.1000584 Ishihara, S. (2017). Stress of patients with cardiovascular disease and their families/caregivers. Stress Science Research. https://doi.org/10.5058/stresskagakukenkyu.2017008 Knowles, K. A., Xun, H., Jang, S. Y., Singh, R., Pang, S., Shan, R., Marvel, F. A., & Martin, S. S. (2019). Clinicians for care: How a systematic literature review informs clinicians on engaging caregivers as part of the cardiovascular care team. Circulation. Schweda, S., & Krauss, I. (2020). Physical activity promotion for multimorbid patients in primary care settings: A protocol for a systematic review evaluating health benefits and harms. Systematic Reviews. https://doi.org/10.1186/s13643-020-01379-6 Svačina, Š. (2020). Obesity and cardiovascular disease. Vnitrni Lekarstvi. https://doi.org/10.4070/kcj.1997.27.1.130 WHO. (2015). Media centre - Cardiovascular Diseases (CVDs). Fact Sheet N. 317. WHO. (2017). Fact Sheet: cardiovascular disease. Cardiovascular Diseases. 2 LITERATURE REVIEW 2 Deliverable 2: Executive Summary Brandy Felicita Rasmussen University Population Health Dr. Merle Point-Johnson Deliverable 2 Submitted July 22, 2021 Cardiovascular disease (CVD) is the primary noncommunicable health problem, leading cause of death in the United States (Howson et al., 2021). United States health care system estimate $531 billion in direct and indirect costs associated with CVD (Matheny et al., 2018). Clinical practice guidelines target primary prevention and recommend that providers evaluate patients for cardiac risk factors (Matheny et al., 2018). To estimate one’s risk of CVD multivariate risk prediction equations are used. This is done by information from the patient’s medical chart and laboratory test. The data is interpretated through tables (Matheny et al., 2018). Risk factors associated with higher risk for CVD include older age, males, high blood pressure, smokers, abnormal cholesterol levels, diabetes mellitus, obesity, and lack of physical activity (Risk Assessment for Cardiovascular Disease with Nontraditional Risk Factors, 2019). Studies show patients with diabetes have an increased risk for cardiovascular disease (Matheny et al., 2018). According to the American Heart Association, individuals with diabetes have a more than double risk of cardiovascular disease (Murphy & Goldman, 2020). The most come cause of death for people with type 2 diabetes is heart disease (Murphy & Goldman, 2020). Education to individuals is key to reducing cardiovascular disease. Individuals with diabetes need to be educated on what this does to his/her body. Such as the tissues use sugar as energy, and it is stored in the liver (Murphy & Goldman, 2020). Individuals with diabetes, the sugar can stay in his/her bloodstream and leak out of the liver and damage the blood vessels and nerves (Murphy & Goldman, 2020). High blood pressure is a common risk factor for cardiovascular disease (Lake County, 2021). Having high blood pressure strains one’s heart and damages blood vessels (Murphy & Goldman, 2020). Individuals with high blood pressure should adhere to a healthy diet, exercise regularly and take required medications (Murphy & Goldman, 2020). High cholesterol can increase one’s risk of cardiovascular disease (Lake County, 2021). This can cause blockages and lead to heart attack (Murphy & Goldman, 2020). Genetics is the main influence in one’s cholesterol (Murphy & Goldman, 2020). However, it is important to make healthy lifestyle choice and maintain exercise (Murphy & Goldman, 2020). Obesity has a strong influence on the above risk factors (Murphy & Goldman, 2020). An effective way to manage weight is to work with nutritionist and exercise regularly (Murphy & Goldman, 2020). Smoking causes a buildup of plaque in one’s arteries. Plaque can cause one to have a heart attack or stroke. Individuals should be educated on the risk of smoking and offered ways to quit smoking. Population Health Management focuses to improve healthcare and it is outcomes by monitoring and accessing patients within a specific focus group. The most effective program collects data from clinical, financial, and operational to help improve efficiency and care. Data sets are an important component when conducting research. Collecting data and analyzing it allows individuals to identify concerns and focus areas. This is completed by using computer software to manipulate the information. Data sets needed for cardiovascular disease is socioeconomic determinants such as education level, occupation, income, ethnicity, sex, and age within a specific area. Data set of clinical and environmental is needed. Clinical review to assess height, weight, and underlying health concerns. Environmental assessment to understand one’s lifestyle and healthy or unhealthy choices such as diet, exercise, and smoking. All the data is necessary to determine an effective way to target individuals for cardiovascular disease risk and implement methods to prevent it. Cardiovascular disease is the leading cause of death in Lake County, Florida (Lake County, 2021). References Howson, C., Reddy, S., Ryan, T., & Bale, J. (2020). Control of Cardiovascular Diseases in Developing Countries. Institute of Medicine. National Academy Press. https://www.nap.edu/read/6218/chapter/1 Lakecountyhealth.gov (2021). Community Health Improvement Plan. http://lake.floridahealth.gov/programs-and-services/community-health-planning-and-statistics/_documents/LakeCo__HealthDeptFinalCHA_10.23.19.pdf Matheny, M., McPheeter, M., & Glasser, A. (2018). Systematic Review of Cardiovascular Disease Risk Assessment Tools. Agency for Healthcare Research and Quality. https://www.ncbi.nlm.nih.gov/books/NBK56158 Murphy, S., Goldman, L. (2020). Understanding the Connection Between Heart Disease and Diabetes. Diabetes and Heart Disease. https://www.healthline.com/health/type-2-diabetes/understanding-cv-disease-diabetes Risk Assessment for Cardiovascular Disease with Nontraditional Risk Factors. (2019). Am Fam Physician. U.S. Preventive Services Task Force. https://www.aafp.org/afp/viewRelatedDepartmentsByDepartment.htm?departmentld=11&page=0 By: Hossin Mosaddad Seminole County Community needs Assesment By: Hossin Mosaddad Current population - 473,408 Median household Income - $66,494 8.7\% of the population live below the federal poverty level 29.4\% of the households have incomes under $50,000 74.9\% of the population is Non-Hispanic and 21.7\% is Hispanic (U.S. Census Bureau, 2019) Major findings from the Community Health Needs Assessment The population of Seminole County, Florida is 473,408 (U.S. Census Bureau, 2019). The average household income is $66,000 (U.S. Census Bureau, 2019). Over 8\% of the population live below poverty level (U.S. Census Bureau, 2019). 2 Unemployment 5\% Poverty Rate 11\% People without health insurance 10\% 109 Overdose death in 2020 (31\% Increase) 17,571 Students In poverty 538 Violent crime offenses (Seminole County, 2021) . Social determinants of health affecting Seminole County residents include 5\% of the population in Seminole County, Florida are unemployed (Seminole County, 2021). Poverty rate is 11\% (Seminole County, 2021). 10\% have no health insurance (Seminole County, 2021). 3 Lack of affordable and adequate housing and homelessness Lack of access to affordable food Lack of good paying jobs, jobs with advancement options, job training Lack of transportation Adverse childhood experiences (ACEs) Increased need of behavioral and mental health services. (Seminole County, 2021) . Social determinants of health affecting Seminole County residents include The social determinants of health affecting Seminole County residents are lack of affordable and adequate housing, lack of access to affordable food, lack of good paying jobs or job advancement, lack of transportation, and increased need of behavioral and mental health services (Seminole County, 2021). 4 IDENTIFIED PRIORITIES: Health Equity Behavioral Health (Including Mental Illness & Substance Abuse) Healthy Weight, Nutrition & Physical Activity (FloridaHealth, 2021) . Community Health Improvement Plan (CHIP) The community health improvement plan know as the CHIP has identified priorities. These priorities include health equity, behavioral health and healthy weight, nutrition and physical activity (FloridaHealth, 2021). 5 Health Equity: Access to Health Care (Mental Health & Dental Care) Affordable Care Poverty/Low Wages Lack of Insurance and Transportation B (FloridaHealth, 2021) . Health Equity Health equity has integrated focus on key elements which include health literacy, access to healthcare, affordable care, poverty and lack of insurance. Focus on these elements present the need to maintain a strong emphasis on care as well as commitment to improved health within the population (FloridaHealth, 2021). 6 Behavioral Health (Including Mental Illness & Substance Abuse) Access to Healthcare (Mental Health) Mental Health/Behavioral Health {Suicide, AGEs) (FloridaHealth, 2021) . IDENTIFIED PRIORITIES The priorities within the social context involve care and commitment to improved level of development. The major issues that are addressed in this case involve behavioural health, access to healthcare. These elements present the basis of a strong emphasis on care which address change development strategy in a given healthcare setting (FloridayHealth, 2021). 7 Health Literacy Affordable Care Access to Health (Mental & Dental Care) Lack of Insurance {Underinsure & Uninsured) Mental Health/Behavioral Health (Suicide, ACEs) (Seminole County, 2021) . Community Health needs Assessment Community health needs involve diverse processes which must be fully integrated within care environment to improve the level and quality of care. The needs within a given setting present a broad context where it is possible to build change and improve the quality of care. Health literacy, affordable care, mental health and access to health present a stronger context for improved care management context (Seminole County, 2021). 8 Hypertension/High Blood Pressure High Cholesterol Obesity and overweight Access to Healthy Affordable Food Dental hygiene/dental care Diabetes (Seminole County, 2021) . Community Health needs Assessment Health challenges within the community are diverse and thus it is imperative to address the common health needs which include high blood pressure, high cholesterol level, obesity, dental hygiene as well as diabetes (Seminole County, 2021). 9 13.5 \% of adults in Seminole county have diabetes 337 deaths per 100,000 in 2018 One of the leading causes of premature deaths in Seminole county. In 2017, roughly 87 men per 100,000 died from diabetes. For women, the rate was 55 deaths per 100,000 (Seminole County, 2021) . Diabetes African Americans and Native Americans have the highest rate of diabetes related mortality (U.S. Census Bureau, 2019). Asians/Pacific Islanders have the lowest (U.S. Census Bureau, 2019). Death related to diabetes is higher in the elderly (U.S. Census Bureau, 2019). 10 Type 1 diabetes is an autoimmune disease 5-10 percent of cases Must take insulin Type 2 diabetes is adult onset 90-95\% of cases Can be prevented Healthy lifestyle changes (Seminole County Diabetes, 2021) Diabetes Diabetes occurs in two ways which include Type 1 and Type 2. Type 1 diabetes occurs in 5-10 \% of the cases. These patients must duly take insulin. Type 2 diabetes is the most common and occurs in around 90 to 95\% of the cases. This can be prevented through a healthy lifestyle (Seminole County Diabetes, 2021). 11 Weight Inactivity Family history Race or ethnicity Age High blood pressure (Seminole County, 2021) Risk Factors There are different elements that are associated with development of diabetes. Older age is associated with increased risk of diabetes with type 2 more common in adults above 50 years. The fattier tissue you have, the more resistant your cells become to insulin. The less active you are, the greater your risk. High blood pressure, family history have also been found to significantly influence the development of diabetes (Seminole County, 2021). 12 (U.S. Census Bureau, 2019) Diabetes This data is based on CDCs multiple cause of death data (U.S. Census Bureau, 2019). Diabetes in noted in the death record but may not be the underlying cause of death (U.S. Census Bureau, 2019). 13 (U.S. Census Bureau, 2019) Diabetes Nationally men are more likely to have diabetes as a cause of death than women (U.S. Census Bureau, 2019). 87 men per 100,000 died from diabetes and 55 women per 100,000 (U.S. Census Bureau, 2019). Women death rate with diabetes continue to decrease (U.S. Census Bureau, 2019). The decrease could be related to differences in behavioral risk factors, access to medical care and biological differences (U.S. Census Bureau, 2019). 14 Teens – Lack of housing and affordable nutritional food Children – Adverse Childhood Experiences (ACEs) and parental stress on a child Intravenous drug users – Endocarditis (infection inside the heart as a result of IV drug use), hepatitis C (due to needle sharing) and sexually transmitted diseases African-Americans have the highest rates of infant mortality per 1,000 births, colorectal cancer and asthma incidences, compared to Whites and Hispanics Whites have the highest rates of breast and lung cancer compared to Blacks and Hispanics. (Seminole County, 2021) . Health inequities identified in Seminole County: Health inequities are inevitable in any given setting since they present a broader basis within which it is possible to improve the quality of care. Lack of housing and affordable nutritional food present a major challenge in delivery of quality care (Seminole County, 2021). 15 Intravenous drug users – Endocarditis (infection inside the heart as a result of IV drug use), hepatitis C (due to needle sharing) and sexually transmitted diseases African-Americans have the highest rates of infant mortality per 1,000 births, colorectal cancer and asthma incidences, compared to Whites and Hispanics Whites have the highest rates of breast and lung cancer compared to Blacks and Hispanics. (Seminole County, 2021) . Key Performance indicators Commitment to improved quality of care present a strong basis within which it is possible to maintain a higher focus on quality healthcare. It is imperative to help create a strong platform to improve the quality of care. Building change involves integration of different approaches which influence the quality of healthcare services (Seminole County, 2021). 16 Increase patient satisfaction by 15\% in a year Decrease obesity rate in the community by 5\% in a year Increase annual primary care visits by 10\% within a year Increase free exercise classes in the community Decrease emergency diabetes cases by 5\% (Gumber & Gumber, 2017). Key performance measures Performance assessment is essential factor that help understand the specific elements that need to be integrated within healthcare quality to improve efficiency and commitment to the need of individuals within the community. Patient satisfaction, internal process quality and financial performance index are crucial elements that present a strong basis to improve the quality of care. Diabetic patients require enhanced care which is crucial in attaining improved level of outcome (Gumber & Gumber, 2017). 17 Personnel Technology systems Expertise and knowledge Financial resources Teamwork (Seminole County, 2021) Current resources available Achieving the set goals requires higher commitment to existing strategies that can help aid improve service delivery. Utilizing available resources forms the basis of change and attaining higher level of engagement. The healthcare setting must effectively focus on using the available resources to attain needed resources. Personnel, technology, expertise and knowledge and financial resources are available resources that can be utilized to advance the set goals (Seminole County, 2021). 18 Multi-centered approach – Ensure cross sectional engagement within healthcare setting with priority to the target group Integrated community care approach – utilize the needs of the community in defining change strategy. Introduce mobile clinics in the community. (Abdoli et al., 2019) Strategies to improve diabetes in the community Improving the level of care engagement within the community require a stronger understanding on change processes which build significant changes that promote change and create a more enhanced basis for improved change and level of engagement. Therefore it would be imperative to ensure the approaches embraced are collaborative and specific in nature based on the underlying problem (Abdoli et al., 2019). 19 Abdoli, S., Jones, D. H., Vora, A., & Stuckey, H. (2019). Improving diabetes care: should we reconceptualize diabetes burnout? The Diabetes Educator, 45(2). 214-224 FloridaHealth.gov (2021). Programs and Services. https://floridahealth.gov Gumber, A., & Gumber, L., (2017). Improving prevention, monitoring and management of diabetes among ethnic minorities: contextualizing the six G’s approach. BMC research notes. 10(1), 1-5 Popeck, L. (2017). Diabetes Rate Rising in Central Florida: How to Reduce Your Risk. Orlando Health. https://www.orlandohealth.com/content-hub/diabetes-rate-rising-in-central-florida-how-to-reduce- your-risk Seminole County Diabetes Death Statistics. (2021). LiveStories. https://www.livestories.com/statistics/florida/seminole-county-diabetes-deaths- mortality Seminolecountyhealth.gov (2021). Community Health Improvement Plan. http://seminole.floridahealth.gov/programs-and-services/community- health-planning-and-statistics/accrediation-performance/_documents/seminole-chna-02-24-2020.pdf U.S. Census Bureau (2019). Quick Facts of Seminole County, Florida. https://www.census.gov/quickfacts/fact/table/seminolecountyflorida . References