Fluent Essays

See attached for assignments 1,2 and 3. This should all be based on the same information.  Scenario Effective population health management (PHM) requires strategies to reach the individual consumer or patient at all stages of life in the manner most appropriate for each individual. PHM must use a set of patterns of population health strategies that describe people and their preferences. These pattern classifications help healthcare organizations begin to understand how they should develop a robust PHM that serves the population needs. Each market and population is unique. Market position, service offerings, health status, predominant diseases, and geographic and community features are all unique factors that need to be addressed. As your healthcare system gains a greater understanding of their local population needs, the PHM program you are implementing needs to develop criteria that will be assigned to specific population cohorts to define the various proactive health interventions and care delivery.   Instructions Write an executive summary that analyzes the various patterns of population health management that your health system is developing for your diverse population. Use five quality references to support your assessment and findings in this assessment. Rubric:  -Analyzes the various patterns of population health management that the health system is developing based on specific examples and fully developed reasoning.  -Incorporates at least 5 quality resources to support assessment and findings. 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 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. Describes what specific data elements are needed to help providers make immediate gains in patient wellbeing while developing best practices for future initiatives with several specific examples and with thorough and detailed reasoning 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. 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). Assess how learning to use more readily available data, like demographics, ICD-10 codes, and ADT alerts, will be a vital first step for integrating much more complex and varied big data into the population health management ecosystem. 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. Population Health Brandy Felicita Dr. Merle Pointe-Johnson Deliverable 1: Community Needs Assessment Community Needs Assessment Lake County Lake County Florida Lake County is located in the center of the State between Orlando and Ocala. Contains over 1,000 lakes and 202 square miles of water. Population is 367,118 (U.S. Census Bureau, 2019) Lake county is in central Florida with the population expected to increase more than the expected growth rate (U.S. Census Bureau, 2019). Health is influenced by conditions where we live and the ability and means to access healthy food, education, affordable housing, and jobs (U.S. Census Bureau, 2019). In Lake County, poverty rates are above 20\% in several cities (U.S. Census Bureau, 2019). 3 Social Determinants Poverty rate-12.8\% Difficulty with employment Utilities being shut off Food shortage Lack of transportation Homelessness Health focus was not until urgent 8.6\% lack access to fresh available drinking water (Lakecountyhealth.gov, 2021) Poverty rate in Lake County increased (Lakecountyhealth.gov, 2021). They struggle with losing utilities and running out of food before they had money to buy more (Lakecountyhealth.gov, 2021). The homeless population is high in Lake County (Lakecountyhealth.gov, 2021). Lake County is a lower income county, people struggle with unemployment and high housing costs (Lakecountyhealth.gov, 2021). Barriers to healthy living are the lack of chronic disease prevention and management services, education on healthy eating and access to affordable, fresh produce, lack of access to care, transportation, and insurance (Lakecountyhealth.gov, 2021). 4 Social Determinants White (Non-Hispanic) 240,160 Black or African American (Non-Hispanic) 3,264 White (Hispanic) 46,508 Black (Non-Hispanic) 34,877 15.9\% of the population is Hispanic or Latino (Lakecountyhealth.gov, 2021) In 2018, the population in Lake County, Florida is majority White, non-Hispanic (Lakecountyhealth.gov, 2021). 5 Social Determinants 312 people are homeless in Lake County. Nationally 1 in 10 homeless individuals are Veterans. (Lakecountyhealth.gov, 2021) Homeless persons are those who lack a fixed, regular, and adequate nighttime residence, or those living in shelters and temporary housing, or public and private places not designed for sleeping accommodations (Lakecountyhealth.gov, 2021). 6 Social Determinants Cardiovascular Diseases is the leading cause of death in Lake County. Risk factors Smoking High cholesterol High blood pressure Physical inactivity Diabetes (Lakecountyhealth.gov, 2021) In 2018, 206 deaths caused from cardiovascular disease in Lake County individuals. Over 35\% of individuals in Lake County are cost burdened (Lakecountyhealth.gov, 2021). 7 Cardiovascular Disease Low education Low income Higher poverty Less healthy choices (Lakecountyhealth.gov, 2021) 80\% of students do not get enough physical activity (Lakecountyhealth.gov, 2021). More than 32\% of adults are obese. Individuals with lower education struggle with higher paying jobs with result in higher poverty (Lakecountyhealth.gov, 2021). Eating healthy is more expensive and more challenging for the lower income individuals (Lakecountyhealth.gov, 2021). Therefore, they are less likely to make healthy choices (Lakecountyhealth.gov, 2021). This results in increased cardiovascular disease (Lakecountyhealth.gov, 2021). 8 Lake County has 7 hospitals Hospital Name Florida Hospital Waterman-Advent Health Leesburg Regional Medical Center Leesburg Rehabilitation Hospital LifeStream Behavioral Center LifeStream Behavioral Center-2 National Deaf Academy South Lake Hospital (County Office, 2021) These hospitals serve a population of over 326,000 people (County Office, 2021). There is 1 hospital every 134 square miles. Lake County is ranked 40th of 67 counties in Hospitals (County Office, 2021). 9 Medical Resources Available Environmental health Health department Wellness programs Family planning (FloridaHealth.gov, 2021) Lake County has multiple environmental areas that promote healthy living (FloridaHealth.gov, 2021). They offer parks that are family friendly. They have walk paths, sporting areas, playground and exercise equipment. The health departments are available and offer many services at reduced costs (FloridaHealth.gov, 2021). For instance, mothers can join the WIC program that helps with formula and healthy supplemental food items for pregnant women and young children (FloridaHealth.gov, 2021). Wellness programs that offer disease prevention, heart disease prevention, and diabetes management (FloridaHealth.gov, 2021). The Florida Department of Health in Lake County is responsible for the surveillance of reportable communicable diseases, vaccine-preventable diseases, invasive bacterial diseases, arthropod-borne diseases, and others (FloridaHealth.gov, 2021). 82\% of lake county residents have access to exercise opportunities (FloridaHealth.gov, 2021). 10 Community Needs Assessment Lake County community needs include, access to primary prevention and healthcare, cardiovascular disease, mental health, education and training. (Lakecountyhealth.gov, 2021) Lake county’s number one health concern is cardiovascular disease (Lakecountyhealth.gov, 2021). Contributing to this is the lack of healthy eating and exercise (Lakecountyhealth.gov, 2021). Due to the poverty level individuals can not afford to eat healthy as it is more expensive (Lakecountyhealth.gov, 2021). Another contributing factor to this is obesity (Lakecountyhealth.gov, 2021). The community needs to be educated on healthy eating and exercise to ensure the reduction of cardiovascular disease. 11 Priority Concerns Lake County community needs concerns Chronic disease screenings Promoting healthy lifestyles Communicable diseases Supporting mental health (Lakecountyhealth.gov, 2021) Chronic disease screenings include; mammograms, PSA, colorectal screenings (Lakecountyhealth.gov, 2021). Promoting healthy lifestyles including poor nutrition, lack of physical activity, unhealthy weight, tobacco/nicotine use, access to healthy food, risk reduction and education (Lakecountyhealth.gov, 2021). Communicable diseases include; HIV/AIDS, Hepatitis, Child and Adult Immunizations (Lakecountyhealth.gov, 2021). Supporting mental health includes lack of services and suicide (Lakecountyhealth.gov, 2021). 12 Steps to improvement Promote Community Wellness Improve Access to Primary Care Decrease Drug Use Healthcare Resources (Institute of Medicine, 2021) Decreasing access to drugs and increasing educational opportunities in middle and high schools while providing treatment in high schools will aid in promoting community wellness (Institute of Medicine, 2021). Improving individuals access to receiving medical care will help with the concerns. Assisting individuals with transportation to and from the doctor office or having mobile clinics would improve the health concerns. Providing education and wellness centers for healthy living would improve overall health (Institute of Medicine, 2021). 13 Community Wellness Decrease Drug Access Increase education in middle and high schools Increase treatment in high schools Increase education to healthy lifestyle Offer exercise classes Offer affordable healthy foods (Lakecountyhealth.gov, 2021) In order to reduce the obesity rate in Lake County, the community can offer affordable healthy foods, exercise classes, and education to the community. Decrease the access to tobacco and drugs especially to minors (Lakecountyhealth.gov, 2021). Provide treatment to high school students when needed (Lakecountyhealth.gov, 2021). 14 Access to Primary Care Increase access to free clinics Increase services provided Decrease cost if needed Provide transportation to individuals in need Mobile clinics (Lakecountyhealth.gov, 2021) Increase low-income families access to providers. Increase local services provided to community. Provide transportation to individuals in need to see his/her primary care physician. Provide mobile clinics to community (Lakecountyhealth.gov, 2021). 15 Decrease Drug Use Education to middle and high school students Treatment to high school students in need Limit the accessibility to tobacco and drugs Have treatment centers available to community Offer counseling (Institute of Medicine, 2021) Drug addicts are typically utilizing drugs to cope or cover pain (Institute of Medicine, 2021). Individuals that have access to medical care and mental health are more successful and can cope without the drug use (Institute of Medicine, 2021). Educating and treating middle and high school students will help identify mental health concerns (Institute of Medicine, 2021). 16 Healthcare Resources Health insurance does not guarantee prevent illness Early intervention is key Long-term Management will help maintain quality of life Minimize premature death Minimize disability (FloridaHealth.gov, 2021) The healthcare concerns in Lake County related to health care resources are emergency rooms are used for routine primary care (FloridaHealth.gov, 2021). Mental health is not considered urgent, so management of this disease is difficult with low income (FloridaHealth.gov, 2021). Individuals are obese and don’t exercise enough causing cardiovascular disease (FloridaHealth.gov, 2021). Without routine check ups and care, individuals will not have access to early intervention (FloridaHealth.gov, 2021). 17 Prevention Initiatives Education to appropriate diet and exercise Routine primary care check ups Education to signs and symptoms of cardiovascular disease Increase cardiac specialist in the area Increase wellness clinics Affordable healthy food plans (FloridaHealth.gov, 2021) Lake County’s top healthcare concern is cardiovascular disease (FloridaHealth.gov, 2021). Individuals need interventions to assist the community with reducing this health concern (FloridaHealth.gov, 2021). Education on healthy diet and access to healthy foods for all individuals no matter the income (FloridaHealth.gov, 2021). Routine check ups from PCP to ensure symptoms are addressed early (FloridaHealth.gov, 2021). 18 Performance Indicators Performance indicators used include: To increase the number of individuals establishing a primary care physician relationship. To decrease risk factors associated with cardiovascular from seeking primary prevention.   To increase percentage of adults who have visited or received services annual checkups. To decrease percentage of cardiovascular disease emergency department, visit rate. To increase percentage of food pantries/banks inventory of healthy food. To reduce rate of deaths related to cardiovascular disease. To decrease obesity rate. (Lakecountyhealth.gov, 2021) Performance indicators are used as a form of measurement to demonstrate if goals are being achieved (Lakecountyhealth.gov, 2021). By implementing education, healthy lifestyles, access to primary health care providers the community can reduce cardiovascular disease. The above indicators are measures the community can use to indicate that the inventions are successful. 19 References County Office (2021). Hospitals in Lake County, Florida. https://www.countyoffice.org/fl-lake-county-hospitals FloridaHealth.gov (2021). Programs and Services. https://floridahealth.gov Institute of Medicine (2021). Primary Care and Public Health: Exploring Integration to Improve Population Health. National Academics Press. https://www.nap.edu/read/13381/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 U.S. Census Bureau (2019). Quick Facts of Lake County, Florida. https://www.census.gov/quickfacts/fact/table/lakecountyflorida