Module 10: Care Coordination and Transition Management: Population Health Management

NOTE: Slides for this session are contained at the back of the PDF handout which is available after module is purchased.

Population health management goes beyond traditional disease management and incorporates both preventive, wellness, and chronic care needs. The goal of population health management is to keep a patient population as healthy as possible. The RN in the CCTM Role uses population health management to organize systems of care for populations; and to identify and implement evidence-based interventions and measure outcomes for both the individual and the population. Patient data including utilization data, medical record data, and evidence based measures are used to stratify the population and aid the RN in identifying patients for outreach. Interventions include closing gaps in evidence based measures and surrounding the patient with support to be successful in self-managing their health. A discussion of evolving health care policy development and its impact on regulatory and payer expectations and the provision of care to define populations will be discussed as will the knowledge, skills, and attitudes necessary for the RN in the CCTM role.

Purpose:
The purpose of this activity is to enable the learner to integrate the principles and key elements of population health management into the RN Care Coordination and Transition Management (RN-CCTM) role.

Recommended Reading:

Linke, S. E., Larsen, B. A., Marquez, B., Mendoza-Vasconez, A., &
    Marcus, B. H. (2016). Adapting Technological Interventions to Meet
    the Needs of Priority Populations. Progress in Cardiovascular
    Diseases, 58(6), 630-638.
    doi:https://doi.org/10.1016/j.pcad.2016.03.001

Sheff, A., Park, E. R., Neagle, M., & Oreskovic, N. M. (2017). The
    patient perspective: utilizing focus groups to inform care
    coordination for high-risk medicaid populations. BMC Research
    Notes, 10(1), 315. doi:10.1186/s13104-017-2638-1

Contact hours available until 7/1/2024.

Learning Outcome:
After completing this learning activity, the learner will be able to integrate the principles and key elements of population health management into the RN Care Coordination and Transition Management (RN-CCTM) role.

Objectives:

1. Explain the purpose of population health management (PHM) and how it applies to the registered nurse (RN) in the Care Coordination and Transition Management (CCTM) role in ambulatory care.
2. Define and describe key elements of PHM.
3. Apply key elements of PHM to RN in CCTM practice.
4. Describe the benefits of having data for managing a population.
5. Discuss methods organizations employ for storage and management of data.
6. Describe the value of stratification of risk within a population.
7. Identify the value of closing gaps in care.
8. Identify key members of the interdisciplinary care team and discuss how they contribute to discipline-based interventions that are a part of population management.
9. Discuss methods to engage and activate patients and their caregivers in partnering in care management.
10. Define and identify wraparound services that are essential for ongoing care and support for populations.
11. Discuss how informatics and decision-support tools are utilized in the provision of population health management.
12. Describe elements for measuring population management from an individual and group perspective.
13. Interpret evolving health care policy development and appropriately comply with quality monitoring, and regulatory and payer expectations in the provision of care to defined populations.
14. Demonstrate the knowledge, skills, and attitudes required for PHM (see Tables 1 and 2).

Requirements for Successful Completion:

1. Read the PDF handout which is the chapter of the CCTM Core Curriculum that corresponds with this module.
2. Listen to the module in its entirety.
3. Complete the online CNE evaluation.

Faculty, Planners and Authors Conflict of Interest Disclosure:
Speaker(s) have no disclosures to declare.

Commercial Support and Sponsorship:
No commercial support or sponsorship declared.

Accreditation Statement:
This educational activity has been co-provided by Anthony J. Jannetti, Inc. and AAACN.

Anthony J. Jannetti, Inc. is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AAACN is a provider approved by the California Board of Registered Nursing, provider number CEP 5366.