Popul Health Manag
· 2026 Feb · PMID 41253390
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Cognitive decline and late-life depression are intertwined public health challenges for aging populations globally. To inform effective prevention, the current study investigated the dynamic temporal associations between...Cognitive decline and late-life depression are intertwined public health challenges for aging populations globally. To inform effective prevention, the current study investigated the dynamic temporal associations between multidimensional cognitive functions and depressive symptoms. Using four waves of longitudinal data (2013-2020) from a large panel study of older adults, the current study employed an integrated framework combining optimized dynamic time warping, cross-lagged panel models, and network analysis to model complex, lagged relationships. Results provided strong empirical support for the "cognition-first" hypothesis, with declines in several cognitive domains-notably temporal orientation, calculation, and immediate recall-acting as significant upstream predictors of subsequent depressive symptoms. A modest but significant protective feedback effect from positive affect to cognitive maintenance was also identified, while negative affect showed no significant predictive role sample of older adults who were cognitively and emotionally healthy at baseline. These findings offer preliminary empirical support for a strategic shift in population health management from reactive treatment toward proactive prevention. Based on these results, the current study discusses a conceptual framework for integrating cognitive screening into primary care to identify at-risk older adults, an approach that warrants further investigation and validation. This proactive approach could enable timely, low-cost interventions aimed at promoting positive affect and cognitive resilience, offering a potentially cost-effective strategy to mitigate the long-term burden of mental illness and advance the goals of healthy aging.
McFayden M, Jain N, Joseph N
… +3 more, Long-Mills E, Whiteside JL, Tumin D
Popul Health Manag
· 2026 Feb · PMID 41204715
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To determine whether pandemic-era Medicaid policies to increase postpartum coverage to 1 year were effective in preventing coverage loss into the second-year postpartum. The analytic sample included 7967 cases ( = 4632 i...To determine whether pandemic-era Medicaid policies to increase postpartum coverage to 1 year were effective in preventing coverage loss into the second-year postpartum. The analytic sample included 7967 cases ( = 4632 in the pandemic era) from the 2019 and 2021-2024 Current Population Survey, Annual Social and Economic Supplement. On multivariable analysis of the entire sample, era was not associated with the type or continuity of insurance coverage. Among families living below 100% Federal Poverty Level, the relative risk of coverage gaps compared with continuous private coverage decreased by 58% (95% confidence interval: 19%, 79%, = 0.010). Pandemic-era Medicaid policies appeared effective in preventing postpartum coverage loss in the second year after birth, especially among families living below the poverty line.
Salzman B, Hersh L, Brucato M
… +3 more, Romano E, Kuperman M, Earland T
Popul Health Manag
· 2025 Dec · PMID 41196007
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Complex care curricula (or "interprofessional student hotspotting") are experiential, longitudinal programs based on complex care practice models where health professions students engage patients with complex health and...Complex care curricula (or "interprofessional student hotspotting") are experiential, longitudinal programs based on complex care practice models where health professions students engage patients with complex health and social needs through personalized, hands-on interventions. Prior studies report mixed impacts of complex care curricula and practice models on hospital readmissions and health care costs, but evaluation of patient-driven goals and outcomes has been sparse. The objective of this study was to characterize the goals of individuals with complex health and social needs that engage with complex care curricula and the associated interventions and barriers reported by interprofessional student teams. Capstone projects of 30 student teams spanning a 5-year period (2015-2020) were analyzed via directed content analysis to identify patient goals, team interventions, and barriers. Thematic analysis revealed that the most common patient goals and team interventions focused on enhancing self-efficacy in managing health (72% and 59%, respectively) and health care system navigation (50% and 69%). Identified barriers fell into 3 major categories: barriers encountered with the health system (28%), related to the individual (66%), and arising in teamwork (50%). Over the course of each curricular cycle, students graduated with an appreciation of the importance of collaborative care for complex patients. The longitudinal impact of this analysis emphasizes patients as key stakeholders in the development of complex care curricula. By deepening our understanding of patient goals, intervention trends, and barriers-we allow for enhanced programming that prepares health professionals for practice, optimizes collaboration on interprofessional health teams, and ensures better outcomes for patients.
Wittink M, Lee N, Pope-Collins E
… +2 more, Holderle K, Maeng D
Popul Health Manag
· 2025 Dec · PMID 41173521
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Patients with co-occurring medical and psychiatric conditions often face fragmented care and prolonged hospitalizations in traditional medical units (MUs). Integrated medical-psychiatry units (MPUs) offer a model of conc...Patients with co-occurring medical and psychiatric conditions often face fragmented care and prolonged hospitalizations in traditional medical units (MUs). Integrated medical-psychiatry units (MPUs) offer a model of concurrent care that may better meet the needs of these patients, but limited data exist on which patient populations benefit most. This study retrospectively compared outcomes for patients with psychiatric conditions discharged from an MPU versus traditional MUs within a single academic medical center between 2019 and 2023. Subgroups included patients presenting with suicidal ideation (SI) or toxic overdose (OD). Primary outcomes were length of stay (LOS) and discharge to the community. MPU patients were younger, more likely to be on Medicaid, and had significantly higher rates of psychotic, mood, substance use, and cognitive disorders (all < 0.001). Despite this higher psychiatric complexity, MPU patients had shorter LOS and higher rates of discharge to home than their counterparts on general MUs, even after adjusting for demographic and clinical differences. Among patients with SI, those on the MPU had an average LOS of 5.5 days compared to 6.7 days in traditional units ( = 0.006). These findings highlight the effectiveness of MPUs in managing complex, high-need patients and support the broader implementation of integrated, interdisciplinary care models to improve hospital outcomes and care transitions for vulnerable populations.
Popul Health Manag
· 2025 Dec · PMID 41051932
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In breast cancer, clinicians add data on social support to patient electronic health records (EHRs) often in free text notes, but those data may be challenging to use for population health initiatives or research purpose...In breast cancer, clinicians add data on social support to patient electronic health records (EHRs) often in free text notes, but those data may be challenging to use for population health initiatives or research purposes. We evaluated the EHR-Support score designed to summarize need for social support using data from the EHR. This study included 996 women from the Pathways study, a Kaiser Permanente Northern California cohort of women diagnosed in 2005-2013 with breast cancer. This unique data resource included both EHR data and questionnaire data on patient-reported social support. Using unstructured EHR data and natural language processing, we developed 11 concept groups (items) characterizing social support. We also used structured data to create two additional concept groups. EHR-Support scores reflecting the lack of social support were generated three ways: counting the number of negative concept groups (count score), using item response theory (IRT), and converting counts to the IRT metric (converted count scores). The count scores were only associated with two of six patient-reported measures (r's: -0.004 to -0.073). The IRT score (r's: -0.038 to -0.179) and converted count score (r's: -0.032 to -0.195) were associated with five of six patient-reported measures, indicating more need for support was associated with less patient-reported social support. The EHR-Support score is a valid and feasible measure of social support that can be used for health services research and managing population health. The converted count score may provide the best balance of validity, precision from IRT and feasibility.
Popul Health Manag
· 2025 Oct · PMID 41021293
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Community health workers (CHW) play a unique role as trusted frontline public health workers who connect underserved populations with health and social services. In addition, CHWs have local insights on underserved patie...Community health workers (CHW) play a unique role as trusted frontline public health workers who connect underserved populations with health and social services. In addition, CHWs have local insights on underserved patients and families, which can help to reduce information gaps and enhance the capacity of health care systems to understand health-related social needs. However, prior reviews have included studies of varying quality, which makes it difficult to assess rigorous evidence from randomized control trial (RCT) studies. Also, many CHW intervention studies do not clearly specify in which organizational setting a CHW is employed. This scoping review of US studies published in the peer-reviewed literature from 2000 to 2023 focuses on RCT studies of CHW interventions by type of organization. A total of 39 studies met all inclusion criteria. Most RCT studies were conducted in health care systems and among safety-net providers, including community health centers. However, only a handful of rigorous RCT studies of CHW interventions were conducted in public health agencies or payer settings (managed care organizations). Overall, most RCT studies of CHW interventions found consistent evidence of improved outcomes. Health care organizations can enhance their efforts to address resource gaps by hiring CHWs or partnering with organizations that employ CHWs. Finally, future RCT studies on CHWs employed by health plans (payers) or public health agencies are needed to bolster the growing body of rigorous evidence that CHWs are highly effective in improving patient outcomes across multiple organizational settings.
Popul Health Manag
· 2025 Oct · PMID 40919660
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Social determinants of health (SDOH) have a greater impact on health outcomes than clinical care. It is essential to address SDOH to improve population health outcomes and achieve success in value-based care models. Prim...Social determinants of health (SDOH) have a greater impact on health outcomes than clinical care. It is essential to address SDOH to improve population health outcomes and achieve success in value-based care models. Primary care delivery models have increased the focus on screening for SDOH to meet these needs. However, there are no publications regarding SDOH screening or addressing social needs in gastroenterology practice. Furthermore, there is no evidence regarding the impact of SDOH screening on the business of gastroenterology practice. This study surveyed community gastroenterologists to explore the potential benefits of addressing SDOH in gastrointestinal specialty care.
Adepoju OE, Xu T, Rollins A
… +4 more, Gronseth S, ElChoufi M, Obanua F, McNeil S
Popul Health Manag
· 2025 Oct · PMID 40833863
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Providing value-based care (VBC) training to relevant stakeholders promotes broader adoption of VBC principles, which in turn can drive improvements in care coordination, patient outcomes, and cost efficiency across the...Providing value-based care (VBC) training to relevant stakeholders promotes broader adoption of VBC principles, which in turn can drive improvements in care coordination, patient outcomes, and cost efficiency across the health system. This study assessed the impact of VBC training on learners' self-reported knowledge and examined how learner characteristics influenced the implementation of VBC principles in professional practice post-training. A 12-week, open online VBC course with 6 modules was developed collaboratively by an academic institution and industry partners. Learners were invited to complete pre- and post-course surveys, and to self-report changes in their knowledge and implementation of VBC principles following course completion. Independent variables included age, geographic residence, education level, biological sex, race/ethnicity, student status, employment status, prior VBC experience, and health care work experience. A linear regression model was used to examine factors associated with increased self-reported knowledge, while logistic regression assessed the relationship between independent variables and the likelihood of learners implementing the course concepts learned in practice. The analytic sample included 715 pre- and post- survey responses. Self-reported knowledge and confidence in VBC concepts increased by 60% by course completion, with 63% of learners reporting early implementation of VBC concepts. Greater increases in self-reported were observed among learners with prior clinical experience and those without prior VBC experience. Learners with higher rates of self-reported VBC implementation were more likely to be female, in full-time employment (35+ hours a week), have prior VBC experience as providers, and undergraduate students. Online VBC education can improve self-reported knowledge and confidence in VBC concepts for a myriad of learners, which translates to increased implementation in health care environments.
Popul Health Manag
· 2025 Oct · PMID 40728062
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This study explored a large segment of Medicare claims data to evaluate the association between Accountable Care Organization (ACO) attribution and 30-day all-cause hospital readmissions. ACOs deliver value-based care to...This study explored a large segment of Medicare claims data to evaluate the association between Accountable Care Organization (ACO) attribution and 30-day all-cause hospital readmissions. ACOs deliver value-based care to attributed patient populations, aiming to enhance care coordination and transitional care outcomes. Initiatives such as the Medicare Shared Savings Program (MSSP) incentivize health care systems to reduce readmissions and the total cost of care. The study included all Medicare inpatient discharges across 50 US states from January 1, 2022, to December 1, 2024. The primary measure of interest was 30-day all-cause readmissions. Hospitalizations for ACO-attributed beneficiaries (readmitted vs. not readmitted) were compared with hospitalizations for non-ACO-attributed beneficiaries. Subgroup and sensitivity analyses were conducted to explore ACO readmission performance with cohorts of beneficiaries with higher levels of clinical complexity and single or multiple hospital admissions. MSSP ACO beneficiaries had a 6% lower rate of 30-day all-cause readmissions. When restricting the cohorts to beneficiaries with higher levels of clinical complexity, MSSP ACO participants had significantly lower readmission rates. Sensitivity analyses adjusting for unequal sample sizes, differences in clinical complexity, and excess zeros (statistical overinflation) indicated that despite the positive effect of multiple hospitalizations, assignment to an ACO was significantly associated with lower readmission risk. The ACO care delivery model is a high-performing care coordination model that exemplifies best practices in addressing transitional care challenges, providing actionable insights for other health care organizations seeking to advance their transitional care strategies within value-based programs.
Popul Health Manag
· 2025 Aug · PMID 40501334
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Physician workload is known to impact provider well-being and individual patient encounters, but less is understood about how provider availability affects broader community health outcomes. Primary care physicians (PCPs...Physician workload is known to impact provider well-being and individual patient encounters, but less is understood about how provider availability affects broader community health outcomes. Primary care physicians (PCPs) often serve as mental health providers, particularly in underserved communities. This study evaluated whether PCP and mental health provider workload, measured by provider-to-resident ratios, predict population-level physical and mental health outcomes. County-level data from the 2024 Robert Wood Johnson Foundation County Health Rankings dataset ( = 3142 counties) were analyzed using two path analysis models; such models are used to estimate both direct and indirect relationships among multiple predictors and outcomes simultaneously. Predictor variables included provider ratios, percent uninsured (mediator), and self-reported physically and mentally unhealthy days (outcomes). Higher PCP workload was significantly associated with greater numbers of poor physical and mental health days. Mental health provider ratios were not directly associated with either outcome. Indirect effects through the percent uninsured were also significant, particularly for physical health outcomes. These findings suggest that PCPs play a disproportionate role in shaping both mental and physical health at the community level. The analysis supports the conclusion that addressing provider shortages and improving insurance coverage can enhance health outcomes, particularly when efforts are integrated into collaborative care models that distribute workload across providers and align treatment approaches with the diverse psychosocial and medical needs of the populations they serve.
Popul Health Manag
· 2025 Aug · PMID 40415569
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The increasing demand for skilled professionals in population health management (PHM) has highlighted the need for a clear understanding of workforce requirements and competencies. This scoping review aims to address thi...The increasing demand for skilled professionals in population health management (PHM) has highlighted the need for a clear understanding of workforce requirements and competencies. This scoping review aims to address this gap by identifying key roles, responsibilities, and competencies necessary for effective PHM implementation. The review was conducted using PubMed and Google Scholar. Articles focusing on PHM workforce requirements, job titles, roles, responsibilities, and competencies were included. Data were extracted and synthesized to address the research questions. A total of 30 records were reviewed, revealing a diverse range of PHM leadership roles, the importance of interdisciplinary teams, and the need for strategic workforce planning. Five core competency domains were identified: Population Health Knowledge and Expertise, Leadership, Data Literacy and Analytics, Business and Operations, and Interpersonal\Communication Skills. Effective PHM implementation requires a diverse, skilled workforce with clearly defined roles and competencies. These findings provide a framework for workforce development and highlight the need for standardized competency-based training in PHM.
Liaw W, Adepoju OE, Luo J
… +10 more, Glasheen B, King B, Kakadiaris I, Prewitt T, Womack P, Dobbins J, Madani M, Shah R, Fuentes CG, Woodard L
Popul Health Manag
· 2025 Aug · PMID 40401431
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Diabetes accounts for 1 in 4 health care dollars spent. Succeeding in value-based payment models depends on identifying those at risk for high costs and providing them with appropriate treatment. The objective was to det...Diabetes accounts for 1 in 4 health care dollars spent. Succeeding in value-based payment models depends on identifying those at risk for high costs and providing them with appropriate treatment. The objective was to determine factors associated with type 2 diabetes mellitus costs. In this cohort study, this study used longitudinal data from a national insurer between 2016 and 2020. The authors included individuals aged 65 and older with type 2 diabetes mellitus with at least 12 months of continuous enrollment in Medicare Advantage. Exclusions included those who died during the study period or had incomplete data. Factors included study year, demographics (age, sex, race/ethnicity, language, dual eligibility, rurality), and diabetes complications (Diabetes Complications Severity Index). The outcomes of interest were medical and prescription costs. The study included 49,843 individuals. Diabetes complications (coefficient = $3582.11, < 0.001), year (coefficient = $1003.22, < 0.001, 2020 vs. 2016), sex (coefficient = $238.35, < 0.001, female vs. male), dual eligibility (coefficient = $618.61, < 0.001, yes vs. no), and rurality (coefficient = $1242.38, < 0.001, yes vs. no) were associated with higher medical costs. Age (coefficient = $-2851.67, < 0.001), race/ethnicity (coefficient = $-1458.03, < 0.001, Black vs. White; coefficient = $-1679.81, < 0.001, Hispanic vs. White), and language (coefficient = $-2523.29, < 0.001, Spanish vs. English) were associated with lower medical costs. Individuals who had complications, were female, were dually eligible, and lived in rural communities had higher medical costs. Black, Hispanic, and Spanish-speaking individuals had lower medical costs, mirroring well-known disparities. Policy makers and health care organizations can use these data to more efficiently deliver care to some while ensuring adequate access for others.
Leaver-Schmidt E, Chambers E, Ciemins E
… +4 more, Rattelman C, Agnihotri P, Casanova D, Kennedy J
Popul Health Manag
· 2025 Jun · PMID 40333658
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Despite ample evidence supporting their efficacy in atherosclerotic cardiovascular disease (ASCVD) management, statin-prescribing and low-density lipoprotein cholesterol (LDL-C) measurement are underused, especially for...Despite ample evidence supporting their efficacy in atherosclerotic cardiovascular disease (ASCVD) management, statin-prescribing and low-density lipoprotein cholesterol (LDL-C) measurement are underused, especially for vulnerable populations. This study explores the impact of a Best Practices Learning Collaborative to improve the management of patients with ASCVD for secondary prevention. Conducted with the guidance of a subject-matter expert advisory committee, the ASCVD Collaborative convened a geographically diverse group of health care organizations (HCOs) over a 12-month implementation period to set goals, develop and implement interventions, collect and track quality performance measures, and share best practices. Interventions included provider/staff education, clinical decision support tools, care coordination, patient education and awareness, and the treatment of very high-risk patients. HCOs tracked three measures for patients with established ASCVD: any statin prescribed (stratified by sex and race/ethnicity), high-intensity statin prescribed, and LDL-C control (<70 mg/dL). After a 12-month implementation period, HCOs demonstrated improvement in one or more measures. The Collaborative model was shown to be an effective means for achieving improvement in the management of ASCVD, laying the groundwork for future more rigorous studies to identify the most impactful interventions.
Chalfin M, Orlov S, Qamar S
… +2 more, Cunningham A, Mills G
Popul Health Manag
· 2025 Jun · PMID 40257914
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Hypertension control remains challenging for many primary care patients. The goal of this study was to implement an evidence-based team approach to improve hypertension control, self-reported health distress, and self-ef...Hypertension control remains challenging for many primary care patients. The goal of this study was to implement an evidence-based team approach to improve hypertension control, self-reported health distress, and self-efficacy in adult patients with hypertension at a large academic family medicine practice. The 5-year intervention included team-based medication therapy management, patient-centered behavioral counseling, and home blood pressure monitoring. Pre- and post-intervention blood pressure and patient surveys were analyzed using paired -tests. The authors observed significant decreases in systolic blood pressure (148.4 vs. 135.6, = 0.001) and self-reported health distress over the enrollment period in participants who completed the study. The multidisciplinary intervention was associated with reduced systolic blood pressure and health distress in patients who enrolled and completed the program. A multidisciplinary blood pressure monitoring program can be implemented by providers referring patients with uncontrolled hypertension after pharmacologic interventions.
Popul Health Manag
· 2025 Aug · PMID 40192556
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Devastating mortality, morbidity, economic, and quality of life impacts have resulted from disasters in the United States. This study aimed to validate a preexisting machine learning (ML) model of household disaster prep...Devastating mortality, morbidity, economic, and quality of life impacts have resulted from disasters in the United States. This study aimed to validate a preexisting machine learning (ML) model of household disaster preparedness. Data from 2021 to 23 Federal Emergency Management Agency's National Household Surveys ( = 21,294) were harmonized. Importance features from the preexisting random forest ML model were transferred and tested in multiple linear and logistic regression models with updated datasets. Multiple regression models explained 42%-53% of the variance in household disaster preparedness. Features that improved the odds of overall disaster preparedness included detailed evacuation plans (odds ratios [OR] = 3.5-5.5), detailed shelter plans (OR = 4.3-11.0), having flood insurance (OR = 1.5-2.0), and higher educational attainment (OR = 1.1). Having no specified source of disaster information lowered preparedness odds (OR = 0.11-0.53). When stratified further by older adults with Black racial identities ( = 350), television as a main source of disaster-related information demonstrated associations with increased preparedness odds (OR = 2.2). These results validate the importance of detailed evacuation and shelter planning and the need to consider flood insurance subsidies in population health management to prepare for disasters. Tailored preparedness education for older adults with low educational attainment and targeted television media for subpopulation disaster-related information are indicated. By demonstrating a feasible use case to import ML model findings for regression testing in new datasets, this process promises to enhance population management health equity for those in sites that do not yet utilize local ML.
Ard J, Kaplan LM, Kahan S
… +9 more, Kumar R, Kan H, Dunn JP, Sims TJ, Ahmad NN, King-Concialdi K, Drakeley S, Jauregui A, Gudzune K
Popul Health Manag
· 2025 Jun · PMID 40170585
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Personal health factors and direct and indirect costs of obesity affect employers and employees. This research aimed to understand perceptions of obesity management and anti-obesity medications (AOMs) among employers and...Personal health factors and direct and indirect costs of obesity affect employers and employees. This research aimed to understand perceptions of obesity management and anti-obesity medications (AOMs) among employers and employees. In 2022, people with obesity and employers completed cross-sectional surveys about perceptions of obesity and its management, including AOMs. Data were analyzed with descriptive statistics. Data from 461 employed people with obesity (EwO) and 51 employer representatives (ER) were analyzed. Both EwO and ER acknowledged the impact of obesity on future health problems (88.3%; 100.0%) and perceived obesity as a disease (60.5%; 80.4%) to varied degrees. Both groups perceived an incremental value in combining self-directed lifestyle changes and AOMs (57.5%; 66.7%) and perceived healthcare provider-guided lifestyle change alongside AOMs as the most effective approach for maintaining long-term weight reduction (56.4%; 66.6%). More than two-thirds (68.6%) of ER expressed willingness to revisit their AOM coverage decisions, though cost of medication coverage (72.5%) and affordability of medications for employees (68.7%) were identified as barriers. ER believed that data showing reductions in premiums and claims at their organizations (78.4%) would be helpful in supporting the coverage of AOMs. While EwO and ER were receptive toward AOMs, organization-level barriers existed with AOM coverage. Evidence demonstrating the benefits of evidence-based obesity care, direct/indirect cost reductions, and the impact of obesity may address barriers to AOM coverage and improve obesity care and outcomes of their workforces.