Population Health Management

Article	Citations
One Year Out: The Five Ds of COVID-19	66
Impact of Social Capital on the Availability of Health Care Services	53
Health Equity Is Key to Better Population Health	51
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	34
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	33
COVID-19 and the Urgent Need for New Therapies for Obesity	31
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	27
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	27
Improve Patient-Centered Care, Decrease Provider Burnout, Maximize Z Codes, Minimize Hierarchical Condition Category Codes	25
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	25
A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship	22
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	21
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	21
A Tale of 4 Babies: Health Equity at the Center of the Quadruple Aim	19
Call for Special Issue Papers: Reducing Health Disparities in Underserved Populations	19
Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension	17
Letter to the Editor: Pivoting Care Coordination Efforts Based on Risk and Return	17
Social Needs Screening in Academic Health Systems: A Landscape Assessment	16
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	15
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	15
Prior Authorization: Process Redesign with a Focus on Value-Based Care	15
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	14
Leveraging Digital Medicine to Support Providers and Their Patients in Managing Serious Mental Illness	14
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	14
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	14

Social Intervention by the Numbers: Evidence Behind the Specific Public Health Guidelines in the COVID-19 Pandemic	13
Operation Allies Welcome Medical Response Unit at Philadelphia International Airport: A Framework for Medical Triage of High Volume of Displaced Persons Arriving by Air	12
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	12
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	12
Measuring What Matters: Beyond Quality Performance Measures in Caring for Adults with Obesity	11
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	11
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	10
Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	10
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	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
A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management	10
Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population	10
The Payvider: An Evolving Model	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
Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates	9
Evaluating the Financial Sustainability of the School-Based Telemedicine Asthma Management Program	9
Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations	9
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
Evaluation of Risk Factors for Hepatitis C Virus Infection Among Philadelphia's Shelter-Bound, Homeless Population: Data from a Student-Run Hepatitis C Virus Screening Initiative	8
Construction of a Pediatrics Risk Score to Predict High Health Care Costs Among a Community Health Center Cohort	8
Leveraging Technology for Value-Based Kidney Care	8
Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach	8
What Is Old Needs to Be New Again	8
Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities	7
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	7
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	7
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	7
Reducing Health Disparities in Underserved Populations: A Spotlight on Health Inequities	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
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	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
The Cost of Unhealthy Days: A New Value Assessment	7
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	6
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	6
Social Isolation Associated with Future Health Care Utilization	6
Health Inequality Among Older Adults with Percutaneous Coronary Intervention and Universal Health Coverage in Japan	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
Mistrust, Neighborhood Deprivation, and Telehealth Use in African Americans with Diabetes	6
What Is a Center of Excellence?	6
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	6
Health Insurance Status of Adults with Hepatitis in the United States: Implications of Results from the National Health Interview Survey, 2013–2018	6
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	6
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	6
Evidence and Implications of the Affordable Care Act for Racial/Ethnic Disparities in Diabetes Health During and Beyond the Pandemic	5
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	5
An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization	5

The Future of Chronic Disease Management	5
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	5
Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change	5
Patient Post-discharge Transitions and Inpatient Readmissions Impose Costly Burdens for Employers and Carriers	5
For Profit, but Socially Determined: The Rise of the SDOH Industry	5
The Academic Payvider Model: Commentary	5
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	5
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	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
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
Reducing the Emergency Department Revolving Door Syndrome for the Poor, Uninsured, and Chronically Ill Patient in Los Angeles: Process Improvement Recommendations from a County Health Program Evaluati	5
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	5
Addressing Social Determinants of Health in Family Medicine Practices	5
Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities	4
A Path to Risk: Critical Elements of a Structured Approach	4
Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	4
Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems	4
Letter to the Editor: Public Health Reform Efforts Should More Effectively Engage Public Health Professionals and the General Public	4
The Unfortunate State of Population Health: Its Omnipresent Promise and Industry's Continued Failure of Vision and Commitment	4
Home-Based Primary Care: A Solution for Our Frail Elderly Patients	4
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	4
Hospital-at-Home: The Good, the Bad, and the Ugly	4
Relationship of Clinician Care Team Composition and Diabetes Quality Outcomes	4
The Impact of Public Health Funding on Population Health Outcomes	4
Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	4
Social Determinants of Health and Comorbidities Among Individuals with Atherosclerotic Cardiovascular Disease: The Behavioral Risk Factor Surveillance System Survey	4
Systematic Review of Care Coordination Interventions Linking Health and Social Services for High-Utilizing Patient Populations	4
The Impact of Expanding Telehealth-Delivered Dietary Interventions on Long-Term Cardiometabolic Health	4
Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak	4
Disruptive Resilience: Harnessing Leadership to Build a More Equitable Health Care System After COVID-19	3
Future Trends to Watch for Value-Based Care	3
Letter to the Editor: Emergency Laparoscopic Cholecystectomy Should Be Performed for Acute Cholecystitis in Trinidad and Tobago	3
Social Determinants of Hepatitis C Virus Infection in the United States, 2016–2021	3
Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population	3
The Clinical and Economic Burdens of Obesity and the Value of Weight Loss for an EMR-Derived US Cohort: A Modeling Study	3
Implementation of Diabetes Prevention in Health Care Organizations: Best Practice Recommendations	3
Mask Up: Academic-Community-Government Partnerships to Advance Public Health During COVID-19	3
Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care	3
“It's Tricky”: Care Managers' Perspectives on Interacting with Primary Care Clinicians	3
Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review	3
Composite Indices of Social Determinants of Health: Overview, Measurement Gaps, and Research Priorities for Health Equity	3
Health Care Bricolage: A Method to Reduce High-Cost Medical Spend	3
Molecular Testing for Women’s Gynecologic Health: Real-World Impact on Health Care Costs	3
Letter to the Editor: Policing is a Public Health Issue	3
The Unrecognized Impact of Anxiety in Complex and Costly Patients	3
Opportunities and Challenges in Screening for Colorectal Cancer	3
Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial	3
The Academic Payvider Model: Care and Coverage	3
Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes	3
Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California	3
Stratifying for Value: An Updated Population Health Risk Stratification Approach	3
Looking Upstream: Promoting Health Equity in Philadelphia through Novel Partnership Strategies	3
Letter to the Editor: Temporal Trends in E-Cigarette and Cigarette Use Among US Adults by US State: Behavioral Risk Factor Surveillance System, 2016 to 2018	3
It Is Time to Supersize Our Population Health Improvement Goals	3
Validation of a 2-Item Food Insecurity Screen Among Adult General Medicine Outpatients	3
Redesign of US Medical Schools: A Shift from Health Service to Population Health Management	3
Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies	3
A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population	3
Electronic Health Data Quality and Population Health Management Algorithms	3
Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines	2
Full-Risk Population Health Programs for Older Adults Like PACE Benefit from COVID-19	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
Social Determinants of Health and After-Hours Electronic Health Record Documentation: A National Survey of US Physicians	2
Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis	2
Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures	2
SARS-CoV-2 Outcomes: The Role of Patient Characteristics and Chronic Disease Comorbidities	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
Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study	2
Global Challenges with Oral Antivirals for COVID-19	2
Association of Unmet Social Needs with Chronic Illness: A Cross-Sectional Study	2
A Call to Action to Increase Uptake of Follow-Up Colonoscopy After Initial Positive Stool-Based Colorectal Cancer Screening	2
Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention	2
Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis	2
Health Systems Need to Transform Data Collection to Advance Health Equity	2
Comparing the Predictive Effects of Patient Medication Adherence Indices in Electronic Health Record and Claims-Based Risk Stratification Models	2
Rural, Underserved, and Minority Populations' Perceptions of COVID-19 Information, Testing, and Vaccination: Report from a Southern State	2
Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models	2

The Key to Success Tomorrow Is Leadership Transformation Today	2
Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives	2
AI and Falls Detection: Great Promise but Gaps in Evidence	2
Health Care Professionals' Perspectives on Universal Screening of Social Determinants of Health: A Mixed-Methods Study	2
Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care	2
Population Health: Staying Focused through the Pandemic and Beyond	2
A Call for Consistent Measurement Across the Social Determinants of Health Industry Landscape	2
How Do Social Needs Cluster Among Low-Income Individuals?	1
Hepatitis C Antibody Screening Among Baby Boomers by a Community-Based Health Insurance Company	1
Evolving Employer-Sponsored Health Care Toward a Post−COVID-19 Marketplace	1
A Population Health-Based Path to Future Models of Health Care	1
Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations	1
Feasibility of Mobile Technology to Identify and Address Patients' Unmet Social Needs in a Primary Care Clinic	1
Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island	1
Impact of Income Disparity on Utilization of Home-Based Care Services Among Older Adults in Japan: A Retrospective Cohort Study	1
Mobile Medical Clinics in the United States Post-Affordable Care Act: An Integrative Review	1
Predictors of Interest in Offered Social Care Assistance Among People with Uncontrolled Diabetes	1
Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance	1
Lessons Learned from the Camden Coalition's Work with High Needs, High Complexity Patients	1
Electronic Health Record-Based Risk Stratification: A Potential Key Ingredient to Achieving Value-Based Care	1
Impact of Area Deprivation Index on the Performance of Claims-Based Risk-Adjustment Models in Predicting Health Care Costs and Utilization	1
Chronic Kidney Disease, Diabetes, and Population Health: From Primary Care to Transplant	1
Utilizing a Dashboard to Promote System-Wide Value in Behavioral Health	1
A Comparison of Emergency Room Visits and Hospital Admissions Between People with Prediabetes and Diabetes	1
Redesigning Diabetes Care for Treatment Inertia: A Population Health Model	1
Permanent Supportive Housing Tenure Among a Heterogeneous Population of Adults with Disabilities	1
Pediatric Population Management Classification for Children with Medical Complexity	1
Building for Value: A Foundational Structure to Support Population Health	1
Gun Violence Prevention Policies Are Not Political: They Are Just Part of Good Public Health	1
Reflections on the Connection Between Health Care Quality and Population Health	1
Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice	1
Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities	1
Mandated Benefits for Diabetes Education and the Availability of Accredited Programs and Certified Diabetes Educators	1
Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity	1
Addressing Gaps in Children's Health Insurance Coverage During the COVID-19 Pandemic	1
Comparing “Meaningful Use” of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties	1
Impact and Continued Relevance of Medication Adherence Measurement	1
Do Refill Gaps Indicate Nonadherence? A Perspective on the Medication Adherence Metric for Quality Rating of Medicare Advantage Plans	1
Genetic Variant Reinterpretation: Economic and Population Health Management Challenges	1
Accelerating Success in Value-Based Care and Population Health: Learnings from a High-Performing Physician Organization	1
Evolution of Population Health Within US Schools of Medicine and Academic Medical Centers	1
Over-the-Counter Hormonal Contraception: The Time Has Come	1
Put All Your Health Investments Under the Same Lens	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
Z Codes for Social Determinants of Health: A Better Predictor of Risk for Value-Based Care	1
Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health	1
Employer Strategies for Health Care Price Transparency	1
Testing Testimonial	1
A Call for an American Social Care System: Social Services Reimbursement to Address Fragmented Care	1
Trends in Mental Health Utilization Before and During the COVID-19 Pandemic: Federally Qualified Health Centers As a Case Study	1
Racial and Ethnic Disparities in Health Information Technology Use and Associated Trends among Individuals Living with Chronic Diseases	1
Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups	1
System-Level Variation in Multiple Sclerosis Care Outcomes: Initial Findings from the Multiple Sclerosis Continuous Quality Improvement Research Collaborative	1
Factors Associated with Chronic Disease and Health Care Utilization Among Young Adults in South Korea	1
Exploring the Relationship Between Local Governmental Spending on the Social Determinants of Health and Health Care Costs of Privately Insured Adults	1
Chart Review Is Dead; Long Live Chart Review: How Artificial Intelligence Will Make Human Review of Medical Records Obsolete, One Day	1
Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population	1
Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort	1
Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations	1
Reckoning with Our Trustworthiness, Leveraging Community Engagement	1
Paradigm Shift Required for Population Health Improvement	1
Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah	1
To Win We Must Change the Game: A Formula for Health Care Transformation	1
Health Care Utilization and Medicaid Spending in Children with Type 1 Diabetes in the Alabama Medicaid Program	1
Operationalizing the Population Health Framework: Clinical Characteristics, Social Context, and the Built Environment	1
Domain Knowledge, Digital Interactions, and Analytics: A Multifaceted Approach to Developing a Population Health Program	1
An Integrated Mobile Acute Care Service Enhances Value	1
Future Role of the Clinical Lab in Population Health	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
The Coming Health Care Transformation: Empowered Patients and Better Value	1