Reducing Cardiovascular Risk for Patients With Diabetes: An Evidence-Based, Population Health Management Program

Abstract

Those with diabetes are at an increased risk of cardiovascular disease (CVD). Safety net clinics serve populations that bear a significant burden of disease and disparities and are a key setting in which to focus on reducing CVD. An integrated health system provided funding and technical assistance (TA) to safety net organizations (community health centers and public hospitals) in Northern California to decrease the risk of cardiovascular events for patients with diabetes. This was a program called Preventing Heart Attacks and Strokes Everyday (PHASE), which combined an evidence-based medication protocol with population health management and team-based care strategies. The TA supported organizations by sharing best practices, providing quality improvement coaching, and facilitating peer learning. A mixed-methods evaluation found that organizations involved in PHASE improved rates of blood pressure control and cardioprotective medication prescriptions for patients with diabetes. They made progress on these measures through strategies such as leveraging team-based care, providing education on evidence-based protocols, and using data to drive improvements. The evaluation concluded that financially supporting and providing focused TA to safety net organizations can help them build capacity and leverage their strengths to improve outcomes and potentially decrease the risk of heart attacks and strokes in communities.

Disentangling Population Health Management Initiatives in Diabetes Care: A Scoping Review

“…Of the 30 full articles reviewed, 20 articles met the eligibility criteria. Through snowballing, five additional studies related to three eligible initiatives were included: three studies related to the Endo ECHO project [32][33][34], one to the INDEPENDENT initiative [35,36], and one to the DM-PEP initiative [37]. In total, 25 studies that described 18 unique selfreported PHM initiatives for type 2 diabetes populations were included.…”

“…Three initiatives were in hospital care [35,50,53,56] and one initiative in pharmaceutical care [48]. The PHASE program was initially implemented in hospital care [50] and subsequently expanded to multiple settings: hospital, regional clinics, and community health centres [37]. The remaining two initiatives were implemented across multiple settings.…”

“…The majority of initiatives included risk stratification (12/18) where only three of these initiatives explicitly mention risk stratification [46,54,55]. In general, PHM initiatives that initially focus on all patients with diabetes apply risk stratification (n = 8) [37,42,45,46,50,51,[53][54][55] and PHM initiatives focusing on a specific segmentation (e.g. high-risk diabetes) do not further stratify the identified population (n = 6) [32, 33, 57, 34, 38-41, 43, 44, 52].…”

“…The most common action was registry development, specifically: electronic health record (EHR) tool or system development [35,38,47,56]; diabetes registry development [45,51,54]; and clinical software, review program, or application development [43,44,49,53]. A second common method to realize or improve the prerequisites for PM was through staff: training staff [32-35, 37, 41, 51, 52, 56], having specific PHM staff or diabetes care staff [16,37,39,40,50], or assigning a population health coordinator [38,56]. System redesign and/or integration of care [16,35,37,46,52,55,56] as well as collaborative care [35,55,56] are additional methods used to achieve this goal.…”

Using big data and Population Health Management to assess care and costs for patients with severe mental disorders and move toward a value-based payment system

“…By focusing on the health needs of a specified population, PHM can integrate and pursue both the Triple Aim (i.e., simultaneously improve population health and outcomes, and reduce costs) [ 7 ] and value-based care, that is, maximizing outcomes while minimizing costs (e.g., through integrating care, measuring outcomes and costs, moving to bundled payments) [ 8 ]. PHM often builds on efforts to integrate care to guide implementation and has been employed for various chronic conditions such as diabetes and congestive heart failure, notably in the United Kingdom (UK) [ 9 , 10 ] and the United States [ 11 – 13 ]; however, its application in MH has been modest [ 4 , 5 , 7 ].…”