Introduction

Leaders in government, business, and health care must address these persistent disparities at the national, state, and local levels, as both an ethical and an economic imperative. In fact, eliminating racial disparities in health care is vital to pushing the entire health care system toward improving quality while containing costs — so-called value-based care. In its 2001 “Crossing the Quality Chasm” report, the Institute of Medicine identified equitable care as one of six core aims of high-value health care systems. And since 2003, Congress has mandated that the federal government produce the annual National Healthcare Disparities Report as part of the effort to monitor national progress in this domain.

Directions

For this unit’s discussion, we will explore incorporating social determinants into population health management. Diabetes is the sixth leading cause of death in the United States. Research indicates that external or upstream factors consistently affect individuals diagnosed with diabetes, influencing self-management. Therefore, research recognizes the need to consider the social determinants of diabetes and health along with individual factors in developing clinical strategies focused on long-term health improvement (Clark & Utz, 2014). 

You are the Director of Population Health Department of a not-for profit healthcare system. The Chief Population Health Officer (CPHO) has scheduled a meeting with you to discuss the impact of social determinants of health on the health outcomes and prognosis of the individuals with diabetes. The CPHO believes that to be able to succeed in population health management initiatives, health systems must take into account the impact of social determinants and health determinants. The CPHO asked you, in preparation for this meeting, to conduct a literature review to examine current understanding of the social determinants and health determinants affecting health of individuals with diabetes, and to provide a corresponding report of the findings.

Questions/what to answer

Prepare your recommendations for creating a population health management program focused on incorporating social determinants and health determinants. 

1. Include the information about conducting a community health assessment and collecting diverse, relevant data pertaining to the population.
2. In your recommendations, be sure to discuss details about stratifying patients according to risk to identify subgroups and individuals most likely to benefit from targeted interventions, and implementation plan for solutions based on the findings.
3. Include the opportunities of developing partnerships with different community-based healthcare provider organizations in effort to support comprehensive care coordination.