Population health management (PHM) has emerged as a central strategy for improving outcomes, reducing avoidable utilization and strengthening system-level performance; however, it remains inconsistently defined and frequently conflated with public health, analytics, or high-performing primary care. This narrative review synthesizes multidisciplinary literature to clarify PHM definitions, compare operational frameworks, identify foundational organizational requirements, and propose a phased implementation pathway grounded in organizational maturity. Searches across major databases identified 42 peer-reviewed articles and authoritative reports published between 2000 and 2024 that addressed PHM conceptual foundations, frameworks, enabling conditions, and implementation strategies. Across diverse models-including accountable care organizations, integrated delivery systems, and national PHM initiatives-common structural components consistently emerged: population attribution and segmentation, targeted intervention design, interoperable data infrastructure, governance alignment, workforce capability, financing integration, and continuous learning. Recurrent barriers included conceptual conflation, fragmented governance, misaligned incentives, and overreliance on analytics without corresponding care redesign. Organizational maturity-rather than analytic sophistication-appears to be the primary determinant of sustainable PHM performance. The evidence suggests that PHM succeeds when conceptual clarity, governance structures, workforce capability, interoperable data systems, and financing alignment coevolve within a deliberate, phased transformation process. Treating PHM as a technical enhancement or isolated program undermines scalability and durability. A maturity-oriented approach provides a practical roadmap for health systems seeking to advance from fragmented initiatives toward sustained population accountability.
Chronic care management (CCM) services may improve disease management and reduce complications for chronically ill patients with multimorbidity. This retrospective study analyzed Medicare claims data (2015-2020) for diabetes patients with multimorbidity, with evaluation and management visits in four U.S. states (Illinois, Iowa, Minnesota, and Wisconsin). The authors assessed differences in diabetes complications among patients receiving CCM services (CCM patients) compared with those not receiving such services (non-CCM patients). The study described patients' characteristics and diabetes-related complications by CCM receipt and identified the frequency of CCM service types (complex and noncomplex). Using propensity-score bounding, covariate and weight-adjusted probabilities of complications were compared across CCM and non-CCM patients. Heterogeneity in estimated probabilities was assessed across states and age categories. Of 5,465,138 visits analyzed, 38,403 visits included CCM services (with noncomplex CCM representing 95.4% of all CCM visits). Regression analyses showed that CCM patients had comparable estimated probability of developing neurological (0.048 vs. 0.046, P = 1.240) complications, lower probability of renal (0.014 vs. 0.017, P < 0.001) and ophthalmical (the least common complication, 0.009 vs. 0.010, P = 0.066) complications, but relatively higher probability of hypoglycemia (the most common complication, 0.070 vs. 0.061, P < 0.001) and circular/vascular (0.034 vs. 0.027 in non-CCM patients, P < 0.001 for the difference) complications than non-CCM patients. There were differences in estimated probability of complications across states and age categories. Non-complex CCM may not suffice to reduce the development of diabetes-related complications among diabetes patients with multimorbidity.
People experiencing homelessness have high medical complexity and are at increased risk for poor post-acute outcomes after hospital discharge, yet evidence on medical respite programs for women is limited. We conducted a retrospective evaluation of a 10-bed medical respite program serving women experiencing homelessness in Northeast Ohio. Records of all women referred between March 2022 and May 2024 were reviewed to assess program implementation and resident outcomes, including health care utilization, health and health management improvement, and housing transitions at discharge. Among 226 referrals, 73 women were admitted. The median age was 56 years, and residents exhibited substantial medical, functional, and behavioral health complexity. At discharge, 45.2% transitioned to permanent housing and 19.2% to skilled nursing facilities. Most residents demonstrated improvements in primary diagnosis status, medication management, self-care ability, and health knowledge, along with reductions in hospitalizations and emergency department visits following admission. Substance use disorder, Medicare enrollment, and history of domestic violence were associated with lower odds of discharge to permanent housing. Medical respite appears to be an effective transitional care intervention for medically fragile women experiencing homelessness, supporting health stabilization, reduced acute care utilization, and housing transitions.
Despite being an important social determinant of health (SDOH), independent association of housing with emergency department (ED) utilization is not well characterized. This study evaluated whether a previously validated ZIP code-level multidimensional housing index is associated with 30-day ED readmission in Maryland. We conducted a retrospective analysis of Maryland ED visits from 2019 to 2023, linked to the American Community Survey housing estimates. The primary outcome was 30-day ED readmission. The variable of interest was a validated ZIP code-level housing index reflecting housing value, quality, occupancy, facilities, transportation access, and cost burden. Multivariable logistic regression was used to adjust for age, sex, race, Elixhauser comorbidity score, and procedure category. Mixed-effects logistic regression with ZIP code random intercepts assessed geographic clustering. Predictive performance was evaluated using 100 repeated 50/50 train-test splits. In 2019, higher housing index was strongly associated with lower odds of readmission in adjusted models (odds ratio [OR] 0.33, 95% CI 0.32-0.34; P < 0.0001), with comparable results generated by the mixed-effects models (OR 0.32, 95% CI 0.29-0.37). This protective association was consistent across all study years. Adding the housing index modestly improved predicting ED readmission in 2019, increasing area under the curve (AUC) from 0.5703 to 0.5888. As a key SDOH, community-level housing conditions were independently associated with reduced 30-day ED readmission. Housing-specific indices may enhance population health risk stratification and inform targeted interventions.
Transitions of care from hospital to home are a vulnerable time for patients, particularly so for those with social determinants of health (SDOH) needs that may impact their ability to manage their health in the outpatient setting. Traditional interventions focus on medication, continuity of care, health information, and red flags and do not necessarily address patients’ SDOH needs. The objective was to evaluate the incorporation of an SDOH screening and intervention into transitions of care encounters (referred to here as CTI+). This is a retrospective analysis of electronic health record data of patients discharged from a large urban health system with a transition of care encounter between May 2022 and April 2024. Demographic characteristics of patients who participate in CTI + are presented, as well as the prevalence of screening positive for issues with health literacy, medical transportation, food insecurity, and financial resource strain. The 30-day readmission rates for patients with SDOH factors and those without were compared, as well as readmission rates in the year prior to and following implementation of CTI+. Of 5942 encounters, 31.9% screened positive for at least one SDOH. 25.6% reported issues with health literacy. Readmission rates rose slightly for each additional positive SDOH factor. After implementation of CTI+, readmissions dropped from 11.7% to 9.8%. These findings highlight the need to address health literacy and demonstrate that incorporating SDOH screening and interventions into transitions of care may help mitigate the effect of SDOH on readmissions.
To examine the associations of sleep quality, sleep duration, and their trajectories with the risk of incident arthritis in middle-aged and older adults in the United Kingdom. Data from waves 4 to 8 of the English Longitudinal Study of Aging were used. We included 3028 participants aged ≥50 years without arthritis at baseline, followed for ∼8 years. Sleep quality was assessed using the Jenkins Sleep Scale (JSS), categorized as good, intermediate, or poor. Sleep duration was divided into tertiles. Incident arthritis was self-reported and physician-diagnosed. Associations were estimated using multivariable logistic regression and stratified analyses, including restricted cubic spline (RCS) models to explore dose-response relationships. Overall, 559 cases of incident arthritis were identified. Both intermediate and good sleep quality were associated with a lower risk of arthritis compared to poor sleep (odds ratio [OR] intermediate = 0.71, OR good = 0.55, P for trend < 0.001). The longest sleep tertile (Q3) showed a modest protective effect (OR = 0.72). RCS analysis revealed a significant linear dose-response relationship between JSS scores and arthritis risk. Sensitivity analyses of sleep-quality trajectories showed lower arthritis risk in all but the stable poor pattern, with the lowest risk in the stable good group (OR = 0.44). Poor subjective sleep quality is a more consistent predictor of arthritis than short-sleep duration alone, with a clear dose-response gradient. Improving poor sleep quality may be key to reducing arthritis risk.
Although patients with uncontrolled diabetes (A1C ≥ 9%) frequently visit their primary care physicians' offices, their diabetes medication is not always changed or intensified at those visits, a pattern described as "therapeutic inertia." One potential solution is the use of point-of-care fingerstick hemoglobin A1C (A1C), which provides results in minutes, rather than venous A1C, which takes days. However, point-of-care A1C is not consistently used in current practice. The authors sought to determine the effectiveness of a systematic nurse-based intervention for implementing point-of-care A1C testing among patients with uncontrolled diabetes. They conducted a before-and-after experimental trial to determine the effect of point-of-care A1C testing on therapeutic inertia in a hospital-based clinic in New York, NY, in 2024-2025. They compared the frequency of any clinical action taken and the time to communication of results to patients before vs. after intervention implementation, using chi-squared and t-tests, respectively. The study included 203 patients, of whom 40.4% were Black or African American and 38.9% were Hispanic. Systematic collection of point-of-care A1C did not change the frequency of clinical actions taken overall (79.0% pre-intervention vs. 73.8% post-intervention, P = 0.38). However, the intervention resulted in a significantly shorter time from test to communication of results to patients, compared to usual care (0.6 days vs. 7.4 days, P = 0.03). A systematic intervention to increase the utilization of point-of-care A1C is effective in facilitating faster delivery of results to patients, which enables more counseling for patients with uncontrolled diabetes during their visit.
Public health professionals have long understood the link between social determinants of health, health-related social needs (HRSN), and health outcomes. Recently, the integration of social care to address HRSN within the health care environment has increased, spurred by payers and health systems recognizing that they will be unable to improve health equity without addressing the underlying nonclinical causes of illness. However, the integration of social care and health care is complex, involving many stakeholders within health care and social care systems, as well as the community. From September 2021 to September 2022, the Institute for Healthcare Improvement, with funding from Pfizer, supported a Learning and Action Network (LAN) involving three integrated delivery networks (IDNs) from across the United States. During the LAN, the IDNs tested social care integration strategies within their patient populations and shared results both with one another and stakeholders in their own systems to enhance the rate of learning and improvement. Detailed here are practical examples from the LAN and learnings from the participating IDNs, with a focus on HRSN screening. This paper presents the quality improvement framework for the LAN, including the use of a three-part data review process and Plan-Do-Study-Act cycles, and documents the successes and challenges faced by each of the IDNs, which include dramatic improvements in HRSN screening rates. Success in this work can be realized with intentional engagement with health care system leadership and the community, closely monitoring implementation, and by evaluating what really matters at the core of this work-achieving health equity.
To date, most bundled payment programs have been voluntary in design. However, such programs are limited by provider and patient selection, the potential exacerbation of health disparities, and results with limited generalizability. In 2026, Medicare will address these concerns through the Transforming Episode Accountability Model (TEAM), the first mandatory program to require nationwide participation across multiple surgical procedures. To anticipate whether the TEAM model can provide generalizable evidence for scaling bundled payments nationwide, the authors used Medicare data to conduct a cross-sectional analysis comparing the characteristics of markets and hospitals selected to participate in TEAM with those that were not. The current study found that, although the 186 TEAM markets were larger than the 618 markets that will not participate, they were similar with regard to structural characteristics (e.g., Medicare advantage penetration, exposure to prior bundled payment programs) and population characteristics (e.g., education, income). The 727 TEAM hospitals differed from the 2155 others with regard to key characteristics, including teaching and safety-net status, profit margin, and patient volume. Overall, these findings suggest that TEAM may generate findings that can be generalized to all US markets while expanding the types of hospitals that have participated in bundled payment programs.
Community Health Needs Assessments (CHNAs), mandated by the Affordable Care Act for tax-exempt hospitals, represent an underutilized yet rich data source for disease-specific advocacy. This commentary proposes a novel framework in which disease advocacy organizations-such as Alzheimer's Los Angeles, the American Heart Association, and the National Alliance on Mental Illness-deploy artificial intelligence (AI) agents to systematically analyze CHNAs, identify gaps in condition-specific care, generate personalized outreach to hospital leadership, and publicly score health systems on their responsiveness to identified needs. Using Alzheimer's disease and dementia care in Los Angeles County as a primary case example, this article describes how AI-driven automation of data collection, natural language processing of CHNA documents, and coordinated advocacy campaigns can transform the current passive CHNA cycle into an active mechanism for population health improvement. The framework combines reputational accountability through public scorecards with constructive, evidence-based recommendations, creating a "carrot-and-stick" dynamic that existing literature on public performance reporting suggests can achieve engagement rates of 40%-70% and meaningful institutional change in 30%-60% of targeted systems. This approach is adaptable across chronic conditions and disease advocacy organizations, wherever publicly reported community needs data intersect with organized patient advocacy. Implications for population health management, health system quality improvement, and the responsible integration of AI in public health advocacy are discussed.
Prior work has shown that persons with disabilities have higher rates of poor cardiovascular outcomes than persons without disabilities. Little research has evaluated this relationship in persons with single and dual sensory loss. This study aimed to examine the association between single and dual sensory loss and cardiovascular disease (CVD). Data were obtained from 2021 Behavioral Risk Factor Surveillance System, a representative household survey of 234,394 noninstitutionalized civilian adults. The independent variable was sensory loss (neither, vision loss only, hearing loss only, both vision and hearing loss). The outcomes were self-reported angina/coronary heart disease, stroke, heart attack, and CVD (composite variable). Covariates were sex, age, race/ethnicity, education, employment, marital status, insurance, income, metropolitan status, body mass index, blood pressure, cholesterol, diabetes, depression, exercise, fruit and vegetable intake, smoking, and alcohol risk. Weighted multivariable logistic regression was used to evaluate the relationship between sensory loss and CVD, adjusting for covariates. In weighted and fully adjusted models, persons with vision loss only, hearing loss only, and dual sensory loss had increased odds of heart attack, stroke, angina/coronary heart disease, and CVD in comparison with persons without sensory loss. Additional research is needed to examine the underlying mechanisms influencing increased risk for CVD in persons with sensory loss. Initiatives are needed that aim to reduce the burden of CVD among persons with single and dual sensory loss.
This study examines the relationship between continuity of care with a family doctor and the usual place of care for minor health problems among Canadian seniors, with a focus on differences between immigrants and the native-born. Data come from the Canadian Health Survey on Seniors (n = 40,848). The outcome identifies respondents' usual source of immediate care for minor problems: a doctor's office, hospital outpatient/community clinic/walk-in clinic, emergency department (ED), or another location. Multinomial logistic regression models estimate associations between continuity of care-measured as duration of attachment to a family doctor-and place of care, with and without interaction terms between continuity and immigrant status, adjusting for demographic, socioeconomic, health, and access-related factors. Seniors attached to a regular family doctor for more than 2 years are significantly less likely to rely on the ED as their usual source of care (OR = 0.89, P < 0.05). Immigrants are also less likely than native-born seniors to use the ED (OR = 0.69, P < 0.001). However, interaction models show that immigrants with short-term attachment (less than 1 year) have higher odds of ED use than native-born seniors with similar attachment (OR = 2.33, P = 0.031). Poor self-rated health, lower income, and access barriers are associated with greater ED reliance. These findings highlight the importance of sustained primary care relationships, particularly for newly attached and immigrant seniors, to reduce avoidable ED use and promote equitable access to community-based care in Canada.
Colorectal cancer (CRC) is a leading contributor to morbidity and mortality in the United States, with documented disparities in screening rates across racial lines. This study examined the intersection of race and social vulnerability in CRC screening rates. We examined 117,424 patients eligible for CRC screening in New York State. We assessed CRC screening among individuals aged 45-80 based on Healthcare Effectiveness Data and Information Set guidelines. We used Social Vulnerability Indices (SVIs) geocoded to each patient's census track. We employed log-binomial multivariate regression models with interaction terms to evaluate the effects of race and social vulnerability on CRC screening rates, while controlling for age, sex, marital status, and community type. Among 117,424 patients eligible for CRC screening, 75.2% of patients (n = 88,276) were effectively screened. Screening rates varied based on race (White 76.2%; Black 64.4%; P < 0.0001). CRC screening rates declined with increasing social vulnerability among both Black and White patients. Among patients in the most socially vulnerable groups, the adjusted rate of screening was 3.8%-8.4% lower for Black patients compared to White patients. In contrast, within the least socially vulnerable (most affluent) group, there was no statistical difference in the rate of CRC screening by race (adjusted risk ratio = 0.981; P = 0.201). The impact of social vulnerability was experienced disproportionately by Black patients. Among patients living in the most vulnerable census tracts, Black patients were significantly less likely to be screened for CRC compared to White patients facing similar social vulnerability. In contrast, we did not observe a difference in screening rates by race in the most affluent (least socially vulnerable) group.
Blood pressure (BP) control is a core quality metric in value-based care (VBC). The Healthcare Effectiveness Data and Information Set (HEDIS) Controlling High Blood Pressure (CBP) measure uses the final BP reading of the calendar year, a method that overlooks well-documented seasonal variation-BP declines in summer and rises in winter. We evaluated the impact of this pattern on measured performance in a large health system. We conducted a retrospective analysis of monthly BP control rates (July 2019 to December 2025) across the Jefferson Health-Lehigh ambulatory network, totaling 78 months and approximately 7.6 million patient-months. Summer (June to August) and winter (December to February) rates were compared using paired t-tests and ordinary least square regression with seasonal adjustment. Year-end performance was assessed using both the HEDIS final-reading (December rate) and a rolling Q4 average (October to December mean). Standard VBC quality improvement initiatives with Q4 intensification were in place. BP control rates were significantly higher in summer (75.2%; 95% confidence interval [CI]: 73.5%-77.0%) than winter (73.1%; 95% CI: 71.2%-75.1%), a 2.1-percentage-point difference (paired t = 5.13, P = 0.002). This pattern was consistent across all 7 years. Within-year peak-to-trough amplitude averaged 2.8 percentage points in nonpandemic years. The rolling Q4 average exceeded the December-only rate in all years, with differences of 0.06-0.59 percentage points, reclassifying 60-520 additional patients as controlled annually. Seasonal BP variation is robust and inadequately addressed by current quality measures. Multi-reading or seasonally adjusted methods would improve measurement accuracy and fairness. Engagement with NCQA and CMS to pilot redesigned measures is recommended.
Substance use disorders (SUDs) have been associated with barriers to preventive medicine screening, but little is known about the association of SUDs and cervical cancer and sexually transmitted infections (STIs) screening rates. This retrospective cohort study used de-identified medical records to select women aged 31-59 as of January 1, 2019. Logistic regression models were computed to estimate the association between any SUDs, including alcohol, compared to no SUD diagnoses, and odds of cervical cancer and STIs screening during the observation period (2019-2024) before and after controlling for covariates. The final cohort included 315,748 people with an average age of 39.4 (±11.6) years old, of whom 22,343 had SUDs. Eighty-two percent were White, and 12.6% were Black individuals. During the 6-year follow-up period, 41% of the cohort received a cervical cancer screening test. After controlling for covariates, individuals with SUDs were less likely to receive cervical cancer screening compared to those without SUDs (odds ratio [OR] = 0.95; 95% confidence interval [CI]: 0.92-0.98). Opioid and sedative use disorders were significantly associated with lower odds of cervical cancer screening (OR = 0.86; 95% CI: 0.81-0.92 and OR = 0.85; 95% CI: 0.72-0.99, respectively). Individuals with SUDs were more likely to receive STI screen compared with those without SUDs (OR = 1.08; 95% CI: 1.05-1.12). An SUD diagnosis is a modest barrier to cervical cancer screening and is associated with more STI screening. Health care professionals must work with multidisciplinary teams to identify and address these barriers.
To examine the structural and health-related risk factors associated with prenatal care (PNC) adequacy among women in North Carolina as measured by the Kotelchuck Prenatal Care Index, a retrospective cohort study was designed to utilize data from the 2017 to 2021 Pregnancy Risk Assessment Monitoring System. The analysis used the independent t-test, chi-square tests, and logistic regression modeling to examine study objectives. The study population comprises 286,835 women with documented live births and recorded Kotelchuck PNC Index scores; 77% received adequate PNC. Receiving adequate PNC was more primarily attributed to White women, married, privately insured, and educated women (P < 0.001). Risk factors such as prepregnancy body mass index (BMI), smoking, diabetes, hypertension, previous preterm birth, and infections significantly impacted adequate PNC, often favoring White women. Black and American Indian/Alaska Native (AI/AN) women had a lower likelihood (P < 0.001) of receiving adequate PNC across BMI categories. AI/AN women who smoked during pregnancy had lower odds of adequate PNC (P < 0.001). Black and AI/AN women with previous poor pregnancy outcomes and previous preterm birth had lower odds of adequate PNC (P < 0.05). Sociodemographic factors, health behaviors, and preexisting medical conditions contribute to pervasive inequities among women of color. Targeted interventions and evidence-informed policy reforms are essential to reducing disparities and improving maternal and neonatal health outcomes.
Traditional medical care accounts for 10% of health outcomes, whereas SDOH account for over 60%. Optimal care of older adults with chronic illnesses requires integration of medical and social service providers. Such partnerships remain uncommon. The authors describe a successful health system/Area Agency on Aging (AAA) integrated team model that meets weekly to discuss challenging community-dwelling older adults and generate care recommendations back to the primary care providers. As part of a quality improvement project, outcomes measured over 6 months during 1 year show a statistically significant decline in the number of important threats to independent living related to the 4Ms (ie, lower fall risk, fewer high-risk medication issues, less behavioral health concerns, and less frequent health care utilization). AAA care managers expressed high satisfaction with the team process and indicated that it helped them address important issues. This model is easily replicated and modifiable to differing local needs. If replicable in rigorously designed research studies, these results would argue for changes in Medicare and Medicaid reimbursement policies to support this interagency integrated model of collaborative care.
The association between pediatric care coordination (PCC) and the prevalence of oral health problems (OHP) among children and youths in the United States was investigated. Using data from the 2022 to 23 National Survey of Children's Health for participants ≤17 years, multivariable Poisson regression models were employed to estimate the association between effective PCC and OHP (the presence of ≥1 parent-reported case of dental caries, gum bleeding, or dental pain). The study estimated the population attributable risk (PAR) to quantify the proportion of potentially avoidable OHP with effective PCC. All models were weighted to account for the complex survey design and adjusted for sociodemographic, health insurance, and geographic covariates. The analytical sample comprised 56,287 participants, representing an estimated target population of 34 million children ≤17 years of age who needed PCC. After controlling for covariates, the difference in the prevalence of OHP between children who received effective PCC (13.1%) and those who did not (17.5%) was statistically significant (adjusted prevalence ratio: 1.33, 95% CI:1.22, 1.44). The PAR was 9.9%, indicating OHP was 9.9% more prevalent among children who lacked effective PCC. Not receiving needed effective PCC was associated with a greater burden of OHP among U.S. children and adolescents. This finding highlights the importance of intentional organization of health services among relevant stakeholders to support optimal oral health.
