Population Health Learning Activities


Diversity and Health Literacy

IP Student Learning Activity related to Knowing and Managing Patients (KM) Competency A — KM8 and Competency B 

An IP student team develops a report assessing language composition and diversity (including racial, ethnic, and at least one other meaningful characteristic of diversity), of the practice’s patient population. NCQA defines diversity as “a meaningful characteristic of comparison for managing population health that accurately identifies individuals within a non-dominant social system who are underserved. These characteristics of a group may include, but are not limited to, race, ethnicity, gender identity, sexual orientation and disability.”

The report should include:

  • A review and assessment of the practice’s materials in languages other than English
  • Recommendations for possible further assessments or strategies to address the practice’s materials in languages other than English
  • A brief literature review of disparities faced by at least one underserved population of the practice
  • Recommendations to help reduce such disparities

This activity should include the students, preferably as a team, interacting with (e.g., interviewing) sufficient numbers of patients from the practice who meet the NCQA definition of “diverse” in order to inform their assessment and/or to obtain feedback on their preliminary assessment and recommendations.

The student team will utilize health literacy tools such as AHRQ’s Health Literacy Universal Precautions Toolkit. Relevant tools may include: Tool 9 “Address Language Differences,” Tool 10 “Consider Culture, Customs, and Beliefs” and Tool 11 “Access, Select, and Create.” 

A draft of the report will be reviewed by the practice and student teams in a group meeting in order to discuss, make revisions and agree on next steps. This meeting should include at least one other health profession from the practice team than is represented in the student team, and if possible, include practice team members whose work is focused on the patient populations concentrated on in the student report.

Learning Objectives (letters/numbers after each objective reference the specific IPEC competency)

  • Recognize the impact of language needs and diversity characteristics on health care and on health.
  • Develop and demonstrate at least two health literacy skills such as are found in AHRQ’s Health Literacy Universal Precautions Toolkit.
  • Assess the health disparities for group of the population served by the practice;
  • Assess patient education materials.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Embrace the cultural diversity and individual differences that characterize patients, populations, and the health care team. (IPEC VE3)
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible (IPEC CC2)
  • Integrate the knowledge and experience of other professions — appropriate to the specific care situation — to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT3)

Note: According to NCQA: “Diversity is a meaningful characteristic of comparison for managing population health that accurately identifies individuals within a non-dominant social system who are underserved. These characteristics of a group may include, but are not limited to, race, ethnicity, gender identity, sexual orientation and disability.”


Population Health Profile

IP Student Learning Activity related to Knowing and Managing Patients (KM) Competency A 

An IP student team develops a health profile of the practice’s patient population or a profile of a subset of the population based on such factors as a health risk, a demographic category, or a diagnosis.

Using select PCMH 2017 Knowing and Managing Patients criteria, the team compiles and analyzes the demographic and clinical data (also incorporating 2017 PCMH Clinical Quality measures found in Performance Measurement and Quality Improvement QI1 & QI2, if desired), formats into a population health profile, includes comparisons with existing community health profiles (see resources below), and identifies challenges faced by the patient population.

Student teams should become familiar with the community health assessment and population health improvement processes, including the most commonly used metrics. Resources include:

Learning Objectives

  • Using health informatics, develop a population health profile that can be effectively used to manage the health of the practices’ patient population.
  • Describe a community health assessment process and some of the most commonly used metrics and data sources.
  • Compare and contrast the patient population of the practice compared with that of the community, county, region, and/or state.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Use available evidence to inform effective teamwork and team-based practices. (IPEC T10)

Population Health Management Review

IP Student Learning Activity related to Knowing and Managing Patients (KM) Competency A; Patient-Centered Access and Continuity (AC) Competency A — AC9; Care Management and Support (CM) Competency A — CM3

A student team reviews the current strategies used by the practice to manage the health of its patient population — identifying areas of effectiveness and possible gaps, and incorporating data from the student team’s Population Health Profile (see corresponding Population Health Learning Activity) – to determine if current practice outreach addresses the population’s needs. Students will then write a report based on their review that includes recommendations for improvement, and present the report to appropriate members of the practice team, who will then determine appropriate improvement actions.

Prior to this activity, student teams should become familiar with community health assessment and population health improvement processes and metrics; see resources listed in Population Health Learning Activity: Population Health Profile

Learning Objectives

  • Develop a report reviewing the practice’s compliance Standard 3 Element D and present findings and recommendations to a practice team.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Integrate the knowledge and experience of other professions— appropriate to the specific care situation—to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT4)
  • Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care. (IPEC TT7)

Patient Engagement and Shared Decision-Making

IP Student Learning Activity related to Knowing and Managing Patients (KM) Competency A — KM8, Competency B, and Competency F — KM22, KM24, and KM25 

An IP student team identifies a common health issue in the practice, determined by the data compiled and needs identified within the Population Health Profile. 

The team reviews the practice’s clinical decision support materials (e.g. point-of-care reminders), other educational materials, self-management tools, decision-making aids, practice or community education programs (including group classes and peer support), and lists of community resources available from the practice for that health issue.

The team then reviews available resources that are best practices and evidence-based, and chooses some for the practice to consider adopting. During this process:

  • A review of the data generated in the Population Health Profile associated with the health issue should be informative to this process. For instance, patient information, clinical data, health assessment data, and qualitative information for and from the patients with the specific health issue may help inform the team of the challenges faced by these patients, and therefore help determine what resources are needed. 
  • If patient or family advocates are available, students should meet with them to review and obtain feedback on the current practice resources and to provide input on plans.
  • Student teams should also obtain feedback and input from practice staff who have relevant expertise.
  • This process should include the students meeting with community partners such as public health, health system, and other non-profit organizations to determine if other community resources are appropriate to add.
  • Student teams may also use the practice’s current materials or ones being considered with patients in order to learn about their efficacy. Some practice with shared decision-making strategies is optimal.
  • The utility of the current and proposed materials should be measured based on national guidance for health literacy, design, and shared decision-making.

Students will then write a draft of their findings and recommendations, meet with and report to the appropriate members of the practice team, who will then determine adjustments to the practice’s resources.

Suggested Resources:

Learning Objectives

  • Develop a review of, assessment of, and recommendations for decision-support tools, self-care and decision-making aids for a particular health issue to assist the practice in meeting its patients’ needs.
  • Demonstrate shared decision-making skills. 
  • Demonstrate health literacy skills when evaluating written materials and when communicating with patients and colleagues.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services. (IPEC VE5)
  • Develop a trusting relationship with patients, families, and other team members. (IPEC 6, CIHC 2010)
  • Manage ethical dilemmas specific to interprofessional patient/population centered care situations. (IPEC VE8)
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Use unique and complementary abilities of all members of the team to optimize patient care. (IPEC RR9)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
  • Develop consensus on the ethical principles to guide all aspects of patient care and team work. (IPEC TT2)
  • Engage other health professionals — appropriate to the specific care situation — in shared patient-centered problem-solving. (IPEC TT3)
  • Integrate the knowledge and experience of other professions — appropriate to the specific care situation — to inform care decisions, while respecting patient and community values and priorities/ preferences for care. (IPEC TT4)
  • Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care. (IPEC TT7)
  • Perform effectively on teams and in different team roles in a variety of settings. (IPEC TT11)

Quality Improvement (QI)

IP Student Learning Activity related to Performance Measurement and Quality Improvement (QI) Competencies A and B

An IP student team, working with the practice’s QI team, will compile data to meet the requirements for one of the following:

  • Clinical Quality Measures: Criterion QI8 
  • Resource Use and Care Coordination: Criterion QI9
  • Patient/Family Experience: Criterion QI11
  • Care of Vulnerable Populations: Criteria QI5 & QI7

The team will analyze the metrics chosen longitudinally (over a time period designated by the practice and appropriate for the measure), note any current strategies underway by the practice to improve the measures and their effectiveness, and provide evidence-based recommendations for further improvements. A review of the data generated in the Population Health Profile associated with the chosen measure may inform this process. Students should engage with members of the practice team who work to improve the chosen metrics and — if possible — with patients and their families/caregivers who are affected by them. The student team may also make evidence-based recommendations to appropriate members of the practice team, including proposed goals and strategies, to improve the measures. The practice team will then determine next steps. 

Vulnerable populations are defined by the PCMH standards as “people who are made vulnerable by their financial circumstances or place of residence, health, age, personal characteristics, functional or developmental status, ability to communicate effectively, and presence of chronic illness or disability,” and include those with multiple co-morbid conditions or who are at high risk for frequent hospitalization or ER visits.  A review of the data generated in the Population Health Profile may help the team to identify vulnerable populations to focus on and determine other barriers they may face.

If time allows, the student team will participate in implementing and studying the QI strategies to complete one cycle of Plan-Do-Study-Act.

Student teams are strongly encouraged to use the following QI resources to guide this activity:

Resources

Learning Objectives

  • Develop a review of, assessment of, and plan for quality measures.
  • Demonstrate the basic principles and skills of healthcare QI as is defined by the Institute of Medicine (IOM): QI consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups. The IOM defines quality in health care as a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations.
  • Articulate some common measures, challenges, impacts on health and healthcare, and strategies related to the chosen QI topic, such as on the chosen quality measures and their uses; resource use and/or care coordination; patient/family experiences; and health disparities.
  • Define mutual support as per TeamSTEPPS;
  • Demonstrate common types of feedback, advocacy, assertion, and conflict resolution TeamSTEPPS tools.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services. (IPEC VE5)
  • Develop a trusting relationship with patients, families, and other team members (IPEC VE6).
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Forge interdependent relationships with other professions to improve care and advance learning. (IPEC RR7)
  • Engage in continuous professional and interprofessional development to enhance team performance. (IPEC RR8)
  • Organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible. (IPEC CC2)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
  • Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict. (IPEC CC6)
  • Share accountability with other professions, patients, and communities for outcomes relevant to prevention and health care. (IPEC TT7)
  • Reflect on individual and team performance for individual, as well as team, performance improvement. (IPEC TT8)
  • Lead a quality improvement activity to increase the effectiveness of interprofessional teamwork and team-based care. (IPEC TT9)
  • Use available evidence to inform effective teamwork and team-based practices. (IPEC TT10)
  • Perform effectively on teams and in different team roles in a variety of settings. (IPEC TT11)

Review of Any Concept

IP Student Learning Activity related to any Concept, Competency or Criterion

An IP student team can review any competency or criterion within a concept, review how the practice implements them, develop recommendations for more fully implementing them, and present to the appropriate members of the practice team. This process can involve: interviewing practice team members to obtain their input; conducting a literature review; researching strategies suggested by NCQA, IHI, AHRQ, and other organizations; and discussing issues with patients.

Resources

Learning Objectives

  • Develop a review of, assessment of, and plan for the implementation of an NCQA standard or element for achieving PCMH recognition.
  • Articulate how PCMH standards and strategies fit into the overall federal health quality initiatives.
  • Place the interests of patients and populations at the center of interprofessional health care delivery. (IPEC VE1)
  • Work in cooperation with those who receive care, those who provide care, and others who contribute to or support delivery of prevention and health services. (IPEC VE5)
  • Develop a trusting relationship with patients, families, and other team members. (IPEC 6, CIHC 2010)
  • Engage diverse healthcare professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific patient care needs. (IPEC RR3)
  • Communicate with team members to clarify each member’s responsibility in executing components of a treatment plan or public health intervention. (IPEC RR6)
  • Use unique and complementary abilities of all members of the team to optimize patient care. (IPEC RR9)
  • Organize and communicate information with patients, families, and healthcare team members in a form that is understandable, avoiding discipline-specific terminology when possible. (IPEC CC2)
  • Listen actively, and encourage ideas and opinions of other team members. (IPEC CC4)
  • Give timely, sensitive, instructive feedback to others about their performance on the team, responding respectfully as a team member to feedback from others. (IPEC CC5)
  • Use respectful language appropriate for a given difficult situation, crucial conversation, or interprofessional conflict. (IPEC CC6)
  • Develop consensus on the ethical principles to guide all aspects of patient care and team work. (IPEC TT2)
  • Engage other health professional — appropriate to the specific care situation — in shared patient-centered problem-solving. (IPEC TT3)
  • Integrate the knowledge and experience of other professions — appropriate to the specific care situation — to inform care decisions, while respecting patient and community values and priorities/preferences for care. (IPEC TT4)
  • Share accountability with other professions, patients and communities for outcomes relevant to prevention and health care. (IPEC TT7)
  • Perform effectively on teams and in different team roles in a variety of settings. (IPEC TT11)