Population Health and Care Coordination
Domain 8 - Population Health and Care Coordination. This domain tests whether you can improve outcomes for a defined group, not just the patient in front of you. Questions often ask which population to target and which intervention will close a gap.
Population health
- Population health is the health outcomes of a group and the distribution of those outcomes. Determinants include social, economic, environmental, behavioral, and clinical factors.
- Tools: registries, risk stratification, the Chronic Care Model, patient-centered medical home, and transitions-of-care programs (medication reconciliation, timely follow-up).
- Payment and accountability: ACOs and shared savings, readmission penalties, HEDIS and Star Ratings, and preventive screening measures.
- CHNA: tax-exempt hospitals assess community health needs every three years and adopt implementation strategies.
Care coordination
- Coordinate across settings with clear handoffs, a named accountable clinician, and shared plans. Address SDOH through screening and referral to community partners.
- Equity means comparing outcomes across subgroups, not just the overall average.
Worked example
A primary-care network finds 55% of diabetic patients meet A1c below 8%, against a 70% target. Reasoning: stratify the registry; identify the largest gap by subgroup and payer; deploy pharmacist medication management, community health worker outreach, and group visits for high-risk patients; track monthly with a run chart; and compare process (screening rate) with outcome (A1c control).
Traps
- Confusing population health with public health.
- Targeting only the highest utilizers and missing broad gaps.
- Ignoring social determinants and access barriers.
- Measuring activity (calls made) rather than outcomes.