Population Health Management

Article	Citations
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	63
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	56
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	43
Improve Patient-Centered Care, Decrease Provider Burnout, Maximize Z Codes, Minimize Hierarchical Condition Category Codes	36
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	34
One Year Out: The Five Ds of COVID-19	24
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	24
Health Equity Is Key to Better Population Health	23
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
A Tale of 4 Babies: Health Equity at the Center of the Quadruple Aim	19
Letter to the Editor: Pivoting Care Coordination Efforts Based on Risk and Return	18
Social Needs Screening in Academic Health Systems: A Landscape Assessment	18
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	16
Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension	16
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	16
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	15
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	15
Prior Authorization: Process Redesign with a Focus on Value-Based Care	14
What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study	14
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	13
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	12
Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	12
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	12
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	11

Operation Allies Welcome Medical Response Unit at Philadelphia International Airport: A Framework for Medical Triage of High Volume of Displaced Persons Arriving by Air	11
A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management	11
Factors Influencing Learners’ Knowledge and Implementation of Value-Based Care Concepts Postcourse Certification	11
Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population	11
Use of a Blood Biomarker Test Improves Economic Utility in the Evaluation of Older Patients Presenting with Cognitive Impairment	11
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	10
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	10
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	10
Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations	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
Reimagining Diabetes Quality Measurement to Advance Quality Care	9
Evaluating the Financial Sustainability of the School-Based Telemedicine Asthma Management Program	8
Reducing Health Disparities in Underserved Populations: A Spotlight on Health Inequities	8
Leveraging Technology for Value-Based Kidney Care	8
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	8
A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic	8
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	8
The Cost of Unhealthy Days: A New Value Assessment	8
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	8
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	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	8
Health Inequality Among Older Adults with Percutaneous Coronary Intervention and Universal Health Coverage in Japan	7
What Is a Center of Excellence?	7
Health Insurance Status of Adults with Hepatitis in the United States: Implications of Results from the National Health Interview Survey, 2013–2018	7
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	7
The Future of Population Health	6
Value-Based Pay-for-Performance Gaps in the Care Delivery Framework for a Large-Scale Health System	6
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	6
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	6
The Role of Social Determinants of Health in Gastroenterology Care	6
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-	6
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	6
Neighborhood-level Social Determinants of Health Improve Prediction of Preventable Hospitalization and Emergency Department Visits Beyond Claims History	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
The Future of Chronic Disease Management	5
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	5
Addressing Social Determinants of Health in Family Medicine Practices	5
Implementation of E-Consults in an Integrated Health System for a Value Population	5
Evidence and Implications of the Affordable Care Act for Racial/Ethnic Disparities in Diabetes Health During and Beyond the Pandemic	5
Mistrust, Neighborhood Deprivation, and Telehealth Use in African Americans with Diabetes	5
The Academic Payvider Model: Commentary	5
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	5
Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	5
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	4
Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	4
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	4

The Impact of Expanding Telehealth-Delivered Dietary Interventions on Long-Term Cardiometabolic Health	4
For Profit, but Socially Determined: The Rise of the SDOH Industry	4
A Path to Risk: Critical Elements of a Structured Approach	4
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	4
Systematic Review of Care Coordination Interventions Linking Health and Social Services for High-Utilizing Patient Populations	4
Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	4
Honoring the Past While Shaping the Future: Reflections From the Incoming Editor-in-Chief	4
Home-Based Primary Care: A Solution for Our Frail Elderly Patients	4
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	4
Social Determinants of Health and Comorbidities Among Individuals with Atherosclerotic Cardiovascular Disease: The Behavioral Risk Factor Surveillance System Survey	4
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	4
Implementation of Diabetes Prevention in Health Care Organizations: Best Practice Recommendations	3
Molecular Testing for Women’s Gynecologic Health: Real-World Impact on Health Care Costs	3
Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population	3
It Is Time to Supersize Our Population Health Improvement Goals	3
Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities	3
Hospital-at-Home: The Good, the Bad, and the Ugly	3
Health Care Bricolage: A Method to Reduce High-Cost Medical Spend	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
Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review	3
A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population	3
Composite Indices of Social Determinants of Health: Overview, Measurement Gaps, and Research Priorities for Health Equity	3
Stratifying for Value: An Updated Population Health Risk Stratification Approach	3
Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems	3
The Unfortunate State of Population Health: Its Omnipresent Promise and Industry's Continued Failure of Vision and Commitment	3
Social Determinants of Hepatitis C Virus Infection in the United States, 2016–2021	3
Looking Upstream: Promoting Health Equity in Philadelphia through Novel Partnership Strategies	3
Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention	3
Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care	3
Electronic Health Data Quality and Population Health Management Algorithms	3
The Academic Payvider Model: Care and Coverage	3
The Unrecognized Impact of Anxiety in Complex and Costly Patients	3
Future Trends to Watch for Value-Based Care	3
Letter to the Editor: Public Health Reform Efforts Should More Effectively Engage Public Health Professionals and the General Public	3
The Impact of Public Health Funding on Population Health Outcomes	3
Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak	3
Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial	3
Disruptive Resilience: Harnessing Leadership to Build a More Equitable Health Care System After COVID-19	3
Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity	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
Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis	2
Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives	2
The Key to Success Tomorrow Is Leadership Transformation Today	2
Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California	2
Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures	2
Social Determinants of Health and After-Hours Electronic Health Record Documentation: A National Survey of US Physicians	2
SARS-CoV-2 Outcomes: The Role of Patient Characteristics and Chronic Disease Comorbidities	2
Hospital Outcomes for Patients with Psychiatric Comorbidities: A Comparison of an Integrated Medical-Psychiatry Unit and Traditional Medical Units	2
Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines	2
Health Systems Need to Transform Data Collection to Advance Health Equity	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
A Call to Action to Increase Uptake of Follow-Up Colonoscopy After Initial Positive Stool-Based Colorectal Cancer Screening	2
Health Care Professionals' Perspectives on Universal Screening of Social Determinants of Health: A Mixed-Methods Study	2
Redesign of US Medical Schools: A Shift from Health Service to Population Health Management	2
Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models	2
Enhancing Machine Learning Explainability of Disaster Preparedness Models from the FEMA National Household Survey to Inform Tailored Population Health Interventions	2
Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations	2
Global Challenges with Oral Antivirals for COVID-19	2
Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study	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
Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis	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
Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies	2
Opportunities and Challenges in Screening for Colorectal Cancer	2
Association of Unmet Social Needs with Chronic Illness: A Cross-Sectional Study	2
Rural, Underserved, and Minority Populations' Perceptions of COVID-19 Information, Testing, and Vaccination: Report from a Southern State	2
System-Level Variation in Multiple Sclerosis Care Outcomes: Initial Findings from the Multiple Sclerosis Continuous Quality Improvement Research Collaborative	2
Impact and Continued Relevance of Medication Adherence Measurement	1
Reckoning with Our Trustworthiness, Leveraging Community Engagement	1
Impact of Income Disparity on Utilization of Home-Based Care Services Among Older Adults in Japan: A Retrospective Cohort Study	1
Evaluation of the Electronic Health Record-Support Social Support Score in Breast Cancer: Comparison of Count and Item Response Theory Scores	1
Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups	1
Z Codes for Social Determinants of Health: A Better Predictor of Risk for Value-Based Care	1
Mobile Medical Clinics in the United States Post-Affordable Care Act: An Integrative Review	1
Permanent Supportive Housing Tenure Among a Heterogeneous Population of Adults with Disabilities	1
Employer Strategies for Health Care Price Transparency	1
Reflections on the Connection Between Health Care Quality and Population Health	1

Chart Review Is Dead; Long Live Chart Review: How Artificial Intelligence Will Make Human Review of Medical Records Obsolete, One Day	1
Cumulative Social Disadvantage and All-Cause Mortality in the United States: Findings from a National Study	1
A Payer–Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes	1
Do Refill Gaps Indicate Nonadherence? A Perspective on the Medication Adherence Metric for Quality Rating of Medicare Advantage Plans	1
Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah	1
Electronic Health Record-Based Risk Stratification: A Potential Key Ingredient to Achieving Value-Based Care	1
Evolution of Population Health Within US Schools of Medicine and Academic Medical Centers	1
Health Care Utilization and Medicaid Spending in Children with Type 1 Diabetes in the Alabama Medicaid Program	1
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
To Win We Must Change the Game: A Formula for Health Care Transformation	1
Building for Value: A Foundational Structure to Support Population Health	1
The Coming Health Care Transformation: Empowered Patients and Better Value	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
Social Determinants of Health and Pediatric Mental Health Before and During COVID-19 in New York City Primary Care Pediatrics	1
Gun Violence Prevention Policies Are Not Political: They Are Just Part of Good Public Health	1
Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice	1
Relationship Between Socioeconomic Deprivation and Healthy Days Among Commercially Insured Adults Using a Digital Health Application: An Observational Study	1
Population Health Futures: Would You Invest Your Personal Money?	1
Accelerating Success in Value-Based Care and Population Health: Learnings from a High-Performing Physician Organization	1
Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance	1
A Comparison of Emergency Room Visits and Hospital Admissions Between People with Prediabetes and Diabetes	1
Put All Your Health Investments Under the Same Lens	1
A Call for an American Social Care System: Social Services Reimbursement to Address Fragmented Care	1
Domain Knowledge, Digital Interactions, and Analytics: A Multifaceted Approach to Developing a Population Health Program	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
Predictors of Interest in Offered Social Care Assistance Among People with Uncontrolled Diabetes	1
Future Role of the Clinical Lab in Population Health	1
Racial and Ethnic Disparities in Health Information Technology Use and Associated Trends among Individuals Living with Chronic Diseases	1
Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis	1
Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island	1
Evolving Employer-Sponsored Health Care Toward a Post−COVID-19 Marketplace	1
Factors Associated with Chronic Disease and Health Care Utilization Among Young Adults in South Korea	1
Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities	1
Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort	1
A Scoping Review of RCT Studies on Community Health Worker Effectiveness	1
Comprehensive Approach to Opioid Management in a Primary Care Network	1
New Drugs for Obesity, Is the Excitement Affordable?	1
Lessons Learned from the Camden Coalition's Work with High Needs, High Complexity Patients	1
Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations	1
Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population	1
Rosalind Franklin Society Proudly Announces the 2023 Award Recipient for Population Health Management	1
Comparing “Meaningful Use” of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties	1