Health of the Public

1
Health of the Public

• Introduction
• What is a population?
• Where are my responsibilities?
• Measuring health status

2
Mrs. Jones

• 55 year old woman employed in fast food industry
• No health insurance benefits seen in residents
  clinic prn
• Diabetes mellitus for 2 years - treated with
  glyburide
• Smokes 1/2 pack/day
• Presents with urinary urgency and frequency

3
Dr. Smith-cognitive disonance

• What needs to be done
• Evaluate primary complaint
• Diabetes
• education
• labs
• referrals
• Health maintenance
• smoking
• cancer sreening
• Financial assistance

• What am I going to get done in the next 30
  minutes??????

4
What is Dr. Smith going to get done in the next
30 minutes?

• Evaluate chief complaint
• according to our office UTI protocol, the nurse
  has
• dipsticked her urine
• attached the following to the patients chart
• a preprinted prescription for trimethoprim/sulfame
  thoxazole
• patient instructions for UTI management
• Dr. Smith reviews her history, performs a brief
  examination, reviews findings, provides
  prescription, and reviews instructions (10 min.)

5
What is Dr. Smith going to get done in the next
30 minutes?

• Provide health maintenance
• according to the office intake protocol, the
  registration clerk has
• identified that the patient
• is a smoker
• has never had a mammogram
• attached the following to the patients chart
• mammogram order form
• sticker indicating that the patient is a smoker
• note that patient is in the precontemplation
  stage
• Dr. Smith recommends mammogram and stresses
  problems of smoking and diabetes (3 min.)

6
What is Dr. Smith going to get done in the next
30 minutes?

• Initiate diabetes management
• the nurse attaches a diabetes flowsheet to the
  chart
• Dr. Smith
• examines patients eyes and feet
• orders Hgb A1C, fasting glucose, and urine for
  microalbumin
• refers patient to nurse to initiate diabetes
  education protocol
• sets up follow-up appointment in 1 week
• (5 min.)

7
What is Dr. Smith going to get done in the next
30 minutes?

• Refer for financial assistance
• Dr. Smith recognizes patient will have difficulty
  paying for diabetes management and provides the
  patient with preprinted referral information for
  social services
• (2 min.)

8
Dr. Smith was ready for Mrs. Jones

• Standardized approach for populations with
• Suspected urinary tract infection
• Nicotine addiction
• Poverty
• 50 year old women with health maintenance needs
• Diabetes

9
Quality Improvement Team Meeting

• 4 PM Wednesday Office Team meeting
• Review data on diabetes care
• Findings
• mean hgb A1c for past six months is 8.1
• opthamology referral rate - 92
• 20/60 patients had not had a foot examination
• Decide to initiate protocol where nurse gets all
  diabetic patients to remove shoes at time of
  check-in
• Plan to re-evaluate in 6 months

10
Population-approach to Health Care in the
Doctors Office

• 4 steps
• Define population
• Determine needs
• Develop systems to address needs
• Evaluate system performance

11
Population-approach to Health Care in the
Doctors Office

• 4 steps
• Define population
• Determine needs
• Develop systems to address needs
• Evaluate system performance

12
Defining the diabetic population

• Routinely code diabetes on billing forms
• Train billing staff to retrieve patient
  identifiers for administrative billing records

13
What other populations has Dr. Smith defined?

• Smokers
• Asthmatics
• Hypertensives
• Children lt 2 years of age
• (for assessing immunizations)

14
Defining a population for measuring influenza
immunizations

• Two types of automated data generally available
  on patients
• insurance data
• name, address, DOB, insurance, gender, etc.
• encounter data (bills for services provided)
• type of service (e.g. an office visit) (CPT
  codes)
• diagnosis (why the service was provided (ICD-9
  codes)
• Practical denominator for measuring influenza
  immunizations age gt 65

15
Population-approach to Health Care in the
Doctors Office

• 4 steps
• Define population
• Determine needs
• Develop systems to address needs
• Evaluate system performance

16
Defining the Needs of the Diabetic Population

• Identify clinical practice guidelines published
  by the ADA
• Extract key performance indicators/goals
• Review proposed performance measures with office
  team

17
How has Dr. Smith identified needs?

• Determined what should be done
• clinical practice guidelines
• focused literature reviews
• Identified common shortcomings
• articles/data on current practice patterns
• Implemented measurements in his own clinic
• chart audits
• patient satisfaction surveys

18
Population-approach to Health Care in the
Doctors Office

• 4 steps
• Define population
• Determine needs
• Develop systems to address needs
• Evaluate system performance

19
Systems to Address Needs of the Diabetic
Population

• Needs assessments
• Education
• Home monitoring
• Office reminders and tracking systems
• Financial support

20
How has Dr. Smith developed his office practice
to provide better care?

• Created office teams to address the needs of
  specific groups of patients (populations)
• Developed better charting tracking systems
• Delegated tasks
• tracking
• patient education
• Identified community resources
• social service for finance
• community support groups

21
Population-approach to Health Care in the
Doctors Office

• 4 steps
• Define population
• Determine needs
• Develop systems to address needs
• Evaluate system performance

22
Why did Dr. Smith want a population approach
for his diabetic patients?

• Standardize needs assessments
• dont let things fall through the cracks
• Delegate office tasks
• train staff to do things for you
• Improve patient education and outcomes
• Document improvements

23
Health of the Public

• Mission
• Variations
• clinic populations
• hospital populations
• community populations

Enable students to be active participants
in improving health of populations
24
HOP Themes

• Population-based medicine
• Health care finance
• Quality of medical care and access
• Systems of medical care
• Occupational medicine
• Small groups
• Capstone Project

25
What is a population?

• Case presentation
• 66 year old female, hypertensive, diabetic,
  smoker presenting with an acute urinary tract
  infection and difficulty paying form Meds
• Brainstorm
• classic definitions
• defining in clinical practice
• defining based on patient characteristics

26
What is your responsibility?

• Choose selected populations
• scale responsibility none -- high

27
Measuring health status for populations

• How do we know how healthy a population is?
• What is being measured?
• Morbidity
• mortality
• lab data
• functional status - SF-36

28
Why would physicians be interested in measuring
the health of a population?

• What if I could identify patients who were likely
  to be readmitted?
• High risk pts -PRA

29
Questions?