Population Health Management

Article	Citations
One Year Out: The Five Ds of COVID-19	57
Health Equity Is Key to Better Population Health	52
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	41
COVID-19 and the Urgent Need for New Therapies for Obesity	34
Implementation of Medications for Alcohol and Opioid Use Disorders in a Value-Based Organization-Unlocking Value by Addressing Unmet Needs for Medicaid and Dually-Eligible Beneficiaries	30
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	23
Improve Patient-Centered Care, Decrease Provider Burnout, Maximize Z Codes, Minimize Hierarchical Condition Category Codes	22
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	22
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	20
A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship	20
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	18
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	18
Call for Special Issue Papers: Reducing Health Disparities in Underserved Populations	17
A Tale of 4 Babies: Health Equity at the Center of the Quadruple Aim	16
Letter to the Editor: Pivoting Care Coordination Efforts Based on Risk and Return	15
Social Needs Screening in Academic Health Systems: A Landscape Assessment	15
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	14
Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension	14
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	13
Prior Authorization: Process Redesign with a Focus on Value-Based Care	12
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	11
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	11
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	11
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	10
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	10

A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management	10
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	10
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	10
Operation Allies Welcome Medical Response Unit at Philadelphia International Airport: A Framework for Medical Triage of High Volume of Displaced Persons Arriving by Air	10
What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study	10
Use of a Blood Biomarker Test Improves Economic Utility in the Evaluation of Older Patients Presenting with Cognitive Impairment	10
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	10
Reimagining Diabetes Quality Measurement to Advance Quality Care	9
Using Health Plan Authorization Data to Predict Hospitalizations and Readmissions in a Combined Commercial and Medicaid Population	9
Body Mass Index and All-Cause and Cardiovascular Mortality in United States Adults With and Without Atherosclerotic Cardiovascular Disease: Findings from the National Health Interview Survey	9
Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population	9
Evaluating the Financial Sustainability of the School-Based Telemedicine Asthma Management Program	9
Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	9
The Payvider: An Evolving Model	8
Leveraging Technology for Value-Based Kidney Care	8
Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations	8
Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach	8
Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates	8
What Is Old Needs to Be New Again	8
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	7
Reducing Health Disparities in Underserved Populations: A Spotlight on Health Inequities	7
Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities	7
Correction to: Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities, by Laura B. Beidler, et al. Popul Health Manag 2023; (vol. 26, no. 5; 283-	7
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	7
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	7
Impact of COVID-19 on the Quadruple Aim	7
A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic	7
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	7
The Cost of Unhealthy Days: A New Value Assessment	7
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	6
Mistrust, Neighborhood Deprivation, and Telehealth Use in African Americans with Diabetes	6
Health Inequality Among Older Adults with Percutaneous Coronary Intervention and Universal Health Coverage in Japan	6
Health Insurance Status of Adults with Hepatitis in the United States: Implications of Results from the National Health Interview Survey, 2013–2018	6
The Future of Population Health	6
Value-Based Pay-for-Performance Gaps in the Care Delivery Framework for a Large-Scale Health System	6
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	6
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	6
What Is a Center of Excellence?	6
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	5
Impact of Pan-Ethnic Expanded Carrier Screening in Improving Population Health Outcomes: Proceedings from a Multi-Stakeholder Virtual Roundtable Summit, June 25, 2020	5
Neighborhood-level Social Determinants of Health Improve Prediction of Preventable Hospitalization and Emergency Department Visits Beyond Claims History	5
An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization	5
For Profit, but Socially Determined: The Rise of the SDOH Industry	5
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	5
Addressing Social Determinants of Health in Family Medicine Practices	5
Patient Post-discharge Transitions and Inpatient Readmissions Impose Costly Burdens for Employers and Carriers	5
Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change	5
Evidence and Implications of the Affordable Care Act for Racial/Ethnic Disparities in Diabetes Health During and Beyond the Pandemic	5
The Academic Payvider Model: Commentary	5
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	5

Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	5
Implementation of E-Consults in an Integrated Health System for a Value Population	5
Home-Based Primary Care: A Solution for Our Frail Elderly Patients	4
Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	4
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	4
A Path to Risk: Critical Elements of a Structured Approach	4
The Future of Chronic Disease Management	4
Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	4
Systematic Review of Care Coordination Interventions Linking Health and Social Services for High-Utilizing Patient Populations	4
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	4
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	4
Social Determinants of Health and Comorbidities Among Individuals with Atherosclerotic Cardiovascular Disease: The Behavioral Risk Factor Surveillance System Survey	4
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	4
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	4
Molecular Testing for Women’s Gynecologic Health: Real-World Impact on Health Care Costs	3
Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak	3
The Impact of Expanding Telehealth-Delivered Dietary Interventions on Long-Term Cardiometabolic Health	3
The Unfortunate State of Population Health: Its Omnipresent Promise and Industry's Continued Failure of Vision and Commitment	3
The Unrecognized Impact of Anxiety in Complex and Costly Patients	3
The Academic Payvider Model: Care and Coverage	3
Electronic Health Data Quality and Population Health Management Algorithms	3
Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review	3
Future Trends to Watch for Value-Based Care	3
Composite Indices of Social Determinants of Health: Overview, Measurement Gaps, and Research Priorities for Health Equity	3
It Is Time to Supersize Our Population Health Improvement Goals	3
The Impact of Public Health Funding on Population Health Outcomes	3
Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems	3
Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities	3
Looking Upstream: Promoting Health Equity in Philadelphia through Novel Partnership Strategies	3
Letter to the Editor: Emergency Laparoscopic Cholecystectomy Should Be Performed for Acute Cholecystitis in Trinidad and Tobago	3
Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes	3
The Clinical and Economic Burdens of Obesity and the Value of Weight Loss for an EMR-Derived US Cohort: A Modeling Study	3
Disruptive Resilience: Harnessing Leadership to Build a More Equitable Health Care System After COVID-19	3
Social Determinants of Hepatitis C Virus Infection in the United States, 2016–2021	3
Hospital-at-Home: The Good, the Bad, and the Ugly	3
Letter to the Editor: Public Health Reform Efforts Should More Effectively Engage Public Health Professionals and the General Public	3
Health Care Bricolage: A Method to Reduce High-Cost Medical Spend	3
Stratifying for Value: An Updated Population Health Risk Stratification Approach	3
Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies	3
Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care	3
A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population	3
Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population	3
Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines	2
A Call for Consistent Measurement Across the Social Determinants of Health Industry Landscape	2
Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures	2
The Key to Success Tomorrow Is Leadership Transformation Today	2
Redesign of US Medical Schools: A Shift from Health Service to Population Health Management	2
Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention	2
Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California	2
Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives	2
Population Health: Staying Focused through the Pandemic and Beyond	2
Rural, Underserved, and Minority Populations' Perceptions of COVID-19 Information, Testing, and Vaccination: Report from a Southern State	2
Review of “Lifelines: A Doctor's Journey in the Fight for Public Health”: A Doctor's Account of Public Health's Invisible and Indispensable Effects	2
Health Systems Need to Transform Data Collection to Advance Health Equity	2
A Call to Action to Increase Uptake of Follow-Up Colonoscopy After Initial Positive Stool-Based Colorectal Cancer Screening	2
Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models	2
Social Determinants of Health and After-Hours Electronic Health Record Documentation: A National Survey of US Physicians	2
Opportunities and Challenges in Screening for Colorectal Cancer	2
Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial	2
Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care	2
AI and Falls Detection: Great Promise but Gaps in Evidence	2
SARS-CoV-2 Outcomes: The Role of Patient Characteristics and Chronic Disease Comorbidities	2
Comparing the Predictive Effects of Patient Medication Adherence Indices in Electronic Health Record and Claims-Based Risk Stratification Models	2
Global Challenges with Oral Antivirals for COVID-19	2
Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis	2
Long Way to Go: Attitudes, Knowledge, and Perception of Artificial Intelligence in Health Care, Among a Racially Diverse, Lower Income Population in Houston, New York, and Los Angeles	2
Enhancing Machine Learning Explainability of Disaster Preparedness Models from the FEMA National Household Survey to Inform Tailored Population Health Interventions	2
Health Care Professionals' Perspectives on Universal Screening of Social Determinants of Health: A Mixed-Methods Study	2
Implementation of Diabetes Prevention in Health Care Organizations: Best Practice Recommendations	2
Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis	2
Association of Unmet Social Needs with Chronic Illness: A Cross-Sectional Study	2
Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity	2
Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study	2
System-Level Variation in Multiple Sclerosis Care Outcomes: Initial Findings from the Multiple Sclerosis Continuous Quality Improvement Research Collaborative	2
Chronic Kidney Disease, Diabetes, and Population Health: From Primary Care to Transplant	1
The Impact of Continuous Use of Home Health Care Resources on End-of-Life Care at Home in Older Patients with Cancer: A Retrospective Cohort Study in Fukuoka, Japan	1
Comparing “Meaningful Use” of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties	1
Redesigning Diabetes Care for Treatment Inertia: A Population Health Model	1
Trends in Mental Health Utilization Before and During the COVID-19 Pandemic: Federally Qualified Health Centers As a Case Study	1
Employer Strategies for Health Care Price Transparency	1

A Call for an American Social Care System: Social Services Reimbursement to Address Fragmented Care	1
Reflections on the Connection Between Health Care Quality and Population Health	1
Population Health Futures: Would You Invest Your Personal Money?	1
Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations	1
Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations	1
Electronic Health Record-Based Risk Stratification: A Potential Key Ingredient to Achieving Value-Based Care	1
Social Determinants of Health and Pediatric Mental Health Before and During COVID-19 in New York City Primary Care Pediatrics	1
Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis	1
New Drugs for Obesity, Is the Excitement Affordable?	1
Predictors of Interest in Offered Social Care Assistance Among People with Uncontrolled Diabetes	1
Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups	1
A Comparison of Emergency Room Visits and Hospital Admissions Between People with Prediabetes and Diabetes	1
Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice	1
Exploring the Relationship Between Local Governmental Spending on the Social Determinants of Health and Health Care Costs of Privately Insured Adults	1
Pediatric Population Management Classification for Children with Medical Complexity	1
To Win We Must Change the Game: A Formula for Health Care Transformation	1
Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island	1
The Coming Health Care Transformation: Empowered Patients and Better Value	1
Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah	1
Racial and Ethnic Disparities in Health Information Technology Use and Associated Trends among Individuals Living with Chronic Diseases	1
Comprehensive Approach to Opioid Management in a Primary Care Network	1
Do Refill Gaps Indicate Nonadherence? A Perspective on the Medication Adherence Metric for Quality Rating of Medicare Advantage Plans	1
Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities	1
Put All Your Health Investments Under the Same Lens	1
Domain Knowledge, Digital Interactions, and Analytics: A Multifaceted Approach to Developing a Population Health Program	1
Building for Value: A Foundational Structure to Support Population Health	1
Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population	1
Mandated Benefits for Diabetes Education and the Availability of Accredited Programs and Certified Diabetes Educators	1
Evolution of Population Health Within US Schools of Medicine and Academic Medical Centers	1
Impact and Continued Relevance of Medication Adherence Measurement	1
Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort	1
Future Role of the Clinical Lab in Population Health	1
Z Codes for Social Determinants of Health: A Better Predictor of Risk for Value-Based Care	1
Permanent Supportive Housing Tenure Among a Heterogeneous Population of Adults with Disabilities	1
Gun Violence Prevention Policies Are Not Political: They Are Just Part of Good Public Health	1
Mobile Medical Clinics in the United States Post-Affordable Care Act: An Integrative Review	1
Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance	1
Evolving Employer-Sponsored Health Care Toward a Post−COVID-19 Marketplace	1
Accelerating Success in Value-Based Care and Population Health: Learnings from a High-Performing Physician Organization	1
Factors Associated with Chronic Disease and Health Care Utilization Among Young Adults in South Korea	1
Health Care Utilization and Medicaid Spending in Children with Type 1 Diabetes in the Alabama Medicaid Program	1
Chart Review Is Dead; Long Live Chart Review: How Artificial Intelligence Will Make Human Review of Medical Records Obsolete, One Day	1
Reckoning with Our Trustworthiness, Leveraging Community Engagement	1
Addressing Gaps in Children's Health Insurance Coverage During the COVID-19 Pandemic	1
Lessons Learned from the Camden Coalition's Work with High Needs, High Complexity Patients	1
Impact of Income Disparity on Utilization of Home-Based Care Services Among Older Adults in Japan: A Retrospective Cohort Study	1