Population Health Management

Article	Citations
Maintaining Safety Standards While Building an Urban Alternate Care Facility in a Global Pandemic	65
“It's Tricky”: Care Managers' Perspectives on Interacting with Primary Care Clinicians	52
Health Equity Is Key to Better Population Health	51
Comparing “Meaningful Use” of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties	46
A Call for an American Social Care System: Social Services Reimbursement to Address Fragmented Care	45
Value-Based Pay-for-Performance Gaps in the Care Delivery Framework for a Large-Scale Health System	34
Health Inequality Among Older Adults with Percutaneous Coronary Intervention and Universal Health Coverage in Japan	33
The Future of Population Health	29
Suppressing the Noise and Raising the Signal in a Marketplace Overwhelmed by Tech-Enabled Solutions	26
Depression and Cost-Related Health Care Utilization Among Persons with Diabetes	26
To Win We Must Change the Game: A Formula for Health Care Transformation	24
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	23
Health and Health Care Use Strongly Associated with Cumulative Burden of Social Determinants of Health	22
Population Health Management Involving a Personalized Health Care Approach: An Example with Cervical Cancer Screening	21
Whole Health in Parts: Omissions from National Data Sets	17
Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies	17
Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes	17
Impact of a Statewide Multi-Payer Patient-Centered Medical Home Program on Antihypertensive Medication Adherence	16
The Impact of Payment Reforms on the Safety Net: Examining Effects of the New Jersey Delivery System Reform Incentive Payment Program on Quality of Care Among Medicaid Beneficiaries	16
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	14
Health Insurance Status of Adults with Hepatitis in the United States: Implications of Results from the National Health Interview Survey, 2013–2018	14
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-	14
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	14
Apply a Venture Investor Mindset to Improve Program Success	13
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	13

Operationalizing the Population Health Framework: Clinical Characteristics, Social Context, and the Built Environment	13
One Year Out: The Five Ds of COVID-19	12
Importance of Community Impact as the Fourth Academic Mission: A Qualitative Study	12
Diabetes and the Tribal Nations	12
Chronic Kidney Disease, Diabetes, and Population Health: From Primary Care to Transplant	12
Evolution of the Care Manager: Redefining Best Practices in the COVID-19 Era	11
Hepatitis C Screening Rates and Care Cascade in a Large US Insured Population, 2010–2016: Gaps to Elimination	11
Disciplinary Intersection of Medicine and Business: A Novel Population Health Management Premedical Pathway for Medicine and Other Health Care Professions	11
Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care	11
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	10
Screening for Social Determinants of Health: Active and Passive Information Retrieval Methods	10
Disruptive Resilience: Harnessing Leadership to Build a More Equitable Health Care System After COVID-19	10
Electronic Health Data Quality and Population Health Management Algorithms	9
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	9
Protecting and Expanding Medicaid Access: Confronting Health Disparities Compounded by COVID-19	9
Implementation of Diabetes Prevention in Health Care Organizations: Best Practice Recommendations	9
The Role of the Private Sector in Advancing Antimicrobial Stewardship: Recommendations from the Global Chief Medical Officers' Network	9
Adult Immunization Measurement: The Road to Progress Following New HEDIS Measures and COVID-19 Vaccination Efforts	9
Celebrating a Silver Anniversary	8
A Critical Appraisal of a University’s Response to a Campus Mass Shooting: Perspectives from Public Health Students and Researchers at Michigan State University	8
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	8
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	8
Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention	7
Impact of Social Capital on the Availability of Health Care Services	7
Redesign of US Medical Schools: A Shift from Health Service to Population Health Management	7
Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial	7
Hepatitis C Antibody Screening Among Baby Boomers by a Community-Based Health Insurance Company	7
Latinx COVID-19 Disparities and Work As a Social Determinant of Health: A Research and Policy Agenda	7
Do Patients Continue to Use Video Visits? Factors Related to Continued Video Visit Use	6
Over-the-Counter Hormonal Contraception: The Time Has Come	6
Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review	6
Factors Associated with Chronic Disease and Health Care Utilization Among Young Adults in South Korea	6
Evaluating Clinical Outcomes of Telehealth as Adjunct to In-Person Care for Older Adults with Diabetes: A Systematic Review of Research Studies	6
Opportunities and Challenges in Screening for Colorectal Cancer	6
The Academic Payvider Model: Care and Coverage	6
Is End of Race-Conscious Admissions the Beginning of an Historically Black Colleges and University Renaissance?	6
COVID-19 and the Urgent Need for New Therapies for Obesity	6
The Impact of a Workforce Mental Health Program on Employer Medical Plan Spend: An Application of Cost Efficiency Measurement for Mental Health Care	6
Improve Patient-Centered Care, Decrease Provider Burnout, Maximize Z Codes, Minimize Hierarchical Condition Category Codes	6
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	6
Clinical Integration of Community Health Workers to Reduce Health Inequities in Overburdened and Under-Resourced Populations	5
Exploring the Relationship Between Local Governmental Spending on the Social Determinants of Health and Health Care Costs of Privately Insured Adults	5
Mobile Medical Clinics in the United States Post-Affordable Care Act: An Integrative Review	5
Mistrust, Neighborhood Deprivation, and Telehealth Use in African Americans with Diabetes	5
Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California	5
A Scoping Review of Behavioral Interventions Addressing Medical Financial Hardship	5
Health Care Professionals' Perspectives on Universal Screening of Social Determinants of Health: A Mixed-Methods Study	5
What Is a Center of Excellence?	5
Association Between Physician Risk Assessment, Hierarchical Condition Categories, and Utilization of Medical Services	5
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	5

Closing the Gap: A Comparison of Engagement Interventions to Achieve Equitable Breast Cancer Screening in Rural Illinois	5
A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population	5
Digital Health: Unlocking Value in a Post-Pandemic World	5
Impact of COVID-19 on the Quadruple Aim	5
Social Isolation Associated with Future Health Care Utilization	4
Mandated Benefits for Diabetes Education and the Availability of Accredited Programs and Certified Diabetes Educators	4
A Tale of 4 Babies: Health Equity at the Center of the Quadruple Aim	4
Future Role of the Clinical Lab in Population Health	4
Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care	4
Effect of a Medicaid Accountable Care Collaborative on 30-Day Hospital Readmission Rates	4
Impact of Pan-Ethnic Expanded Carrier Screening in Improving Population Health Outcomes: Proceedings from a Multi-Stakeholder Virtual Roundtable Summit, June 25, 2020	4
A Population Health-Based Path to Future Models of Health Care	4
The Human in the Middle: Artificial Intelligence in Health CareSummary ProceedingsSymposium Presentation and Reactor Panel of ExpertsThomas Jefferson UniversityDecember 10, 2019	4
A Call to Action to Increase Uptake of Follow-Up Colonoscopy After Initial Positive Stool-Based Colorectal Cancer Screening	4
In the “Drivers′” Seat: How to Improve Drivers of Health, from Vision to Impact	4
Letter to the Editor: Risk of Suicide in People Whose Family Members Have Died from COVID-19: The Importance of an Empathetic Relationship in Medical Care and Psychological Help	4
The Social Risk ACTIONS Framework: Characterizing Responses to Social Risks by Health Care Delivery Organizations	4
Effect of Care Rehabilitation on Medical Expenses, Care Costs, and Total Costs of Elderly Individuals with Parkinson's Disease	4
Insights into the Use of Digital Tools for People with Mental Health Disorders	4
Letter to the Editor: Pivoting Care Coordination Efforts Based on Risk and Return	4
Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis	4
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	4
Short- and Long-Term Health Consequences of Gaps in Health Insurance Coverage among Young Adults	4
Factors Associated with Entering the Prescription Drug Coverage Gap Among Medicare Beneficiaries with Chronic Obstructive Pulmonary Disease	3
Impact of the COVID-19 Pandemic on Blood Lead Testing in Children in the United States	3
Community-Based Mental Health Improvement Initiatives: A Narrative Review and Indiana Case Study	3
Addressing Social Determinants of Health in Family Medicine Practices	3
Impact of Income Disparity on Utilization of Home-Based Care Services Among Older Adults in Japan: A Retrospective Cohort Study	3
Development of a Logic Model to Guide Implementation and Evaluation of a Mobile Integrated Health Transitional Care Program	3
Redesigning Diabetes Care for Treatment Inertia: A Population Health Model	3
Patient Perception and Impact of Home Test Kits on Health Care Utilization for Urinary Tract Infection	3
Social Needs Screening in Academic Health Systems: A Landscape Assessment	3
Feasibility of Mobile Technology to Identify and Address Patients' Unmet Social Needs in a Primary Care Clinic	3
The Key to Success Tomorrow Is Leadership Transformation Today	3
Long-Term HIV Pre-Exposure Prophylaxis Persistence and Reinitiation in Connecticut from 2012 to 2018	3
The Academic Payvider Model: Commentary	3
Call for Special Issue Papers: Reducing Health Disparities in Underserved Populations	3
Diabetes Education Desert: Regional Disparity Between Diabetes Prevalence and Diabetes Self-Management Education Programs in Texas	3
Patient Post-discharge Transitions and Inpatient Readmissions Impose Costly Burdens for Employers and Carriers	3
Impact and Continued Relevance of Medication Adherence Measurement	3
Social Determinants of Health and After-Hours Electronic Health Record Documentation: A National Survey of US Physicians	3
Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups	3
Building for Value: A Foundational Structure to Support Population Health	3
Neighborhood-level Social Determinants of Health Improve Prediction of Preventable Hospitalization and Emergency Department Visits Beyond Claims History	3
A Missed Opportunity? How Health Care Organizations Engage Primary Care Clinicians in Formal Social Care Efforts	3
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	3
Pediatric Population Management Classification for Children with Medical Complexity	3
Health Care Worker Burnout and Perceived Capacity to Address Social Needs	3
Addressing Gaps in Children's Health Insurance Coverage During the COVID-19 Pandemic	3
Conceptualizing and Defining Anchor Businesses to Facilitate Investments in Community Health and Well-Being	3
Evidence and Implications of the Affordable Care Act for Racial/Ethnic Disparities in Diabetes Health During and Beyond the Pandemic	3
Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis	3
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	3
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	3
Impact of Patient-Centered Medical Home Transformation on Providers, Staff, and Quality	3
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	3
Chart Review Is Dead; Long Live Chart Review: How Artificial Intelligence Will Make Human Review of Medical Records Obsolete, One Day	2
Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures	2
AI and Falls Detection: Great Promise but Gaps in Evidence	2
Domain Knowledge, Digital Interactions, and Analytics: A Multifaceted Approach to Developing a Population Health Program	2
The Proportion of Marginalized Individuals in US Communities and Hospital Participation in Bundled Payments	2
Willingness to Follow Mask Mandates Increases Over Two-Month Period	2
Commentary Contributors	2
Testing Testimonial	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
Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension	2
Additive Impact of Virtual Urgent and Emergency Department at Home Care on Value-Based Primary Care for Medicaid and Dual-Eligible Members	2
Association of Unmet Social Needs with Chronic Illness: A Cross-Sectional Study	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
Utilizing a Dashboard to Promote System-Wide Value in Behavioral Health	2
Implementation of E-Consults in an Integrated Health System for a Value Population	2
Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis	2
Emerging Health System, Provider, and Payer Opportunities in Population Health Delivery	2
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	2
Evaluation of the Predictive Value of Routinely Collected Health-Related Social Needs Measures	2
Prescribing Housing: A Scoping Review of Health System Efforts to Address Housing as a Social Determinant of Health	2
Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	2
Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives	2
Reach of a Fully Digital Diabetes Prevention Program in Health Professional Shortage Areas	2
Prior Authorization: Process Redesign with a Focus on Value-Based Care	2

Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change	2
Global Challenges with Oral Antivirals for COVID-19	2
COVID-19 and Health Care at Home: A Catalyst for Population Health Management	2
Causes of Death Among Health Care Professionals in the United States	2
Health Systems Need to Transform Data Collection to Advance Health Equity	2
Patient-Provider Communication and Adherence to Cholesterol Management Advice: Findings from a Cross-Sectional Survey	2
Precision Medicine for Populations: The Future of Medication Management	2
Toward Successful and Sustainable Statewide Screening for Social Determinants of Health: Testing the Interest of Hospitals	2
The Evolution of Population Health Management: Time to Accredit the Curriculum?	2
Population Health Strategies to Support Hospital and Intensive Care Unit Resiliency During the COVID-19 Pandemic: The Italian Experience	1
Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines	1
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	1
Operation Allies Welcome Medical Response Unit at Philadelphia International Airport: A Framework for Medical Triage of High Volume of Displaced Persons Arriving by Air	1
Health Care Utilization and Medicaid Spending in Children with Type 1 Diabetes in the Alabama Medicaid Program	1
Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity	1
Put All Your Health Investments Under the Same Lens	1
Clinical and Cost Benefits of Anti-Obesity Medication for US Veterans Participating in the MOVE! Weight Management Program	1
Facing the COVID-19 Pandemic in France: From Managerialism to Business Logistics	1
Home-Based Primary Care: A Solution for Our Frail Elderly Patients	1
Hospital Inpatient Charges of COVID-19 Diagnostic Tests Ranged from $10 to $1390	1
Addressing the Social Needs of Medicaid Enrollees Through Managed Care: Lessons and Promising Practices from the Field	1
Implementation of a Pediatric Population Health Asthma Program in Academic Medical Center-Affiliated Urban and Suburban Practices	1
An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization	1
Association Between Broadband Capacity and Social Vulnerability Factors in the United States: A County-Level Spatial Analysis	1
Letter to the Editor: Temporal Changes in Cost-Related Medication Nonadherence by Race/Ethnicity and Medicaid Expansion: The Behavioral Risk Factor Surveillance System Survey	1
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	1
Knowledge, Attitudes, and Practices Regarding Herpes Zoster Vaccination Among Specialists	1
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	1
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	1
Preventing Colorectal Cancer: Pathway to Achieving an 80% Screening Goal in the United States: Overview and Proceedings of a Population Health Advisory Board	1
The Future of Chronic Disease Management	1
New Drugs for Obesity, Is the Excitement Affordable?	1
Do Refill Gaps Indicate Nonadherence? A Perspective on the Medication Adherence Metric for Quality Rating of Medicare Advantage Plans	1
Multi-Sector Partnerships and Networks to Support Social Health, Medical Education, and Return on Investment	1
Paradigm Shift Required for Population Health Improvement	1
Population Health: Staying Focused through the Pandemic and Beyond	1
Understanding Caregiver Perspective on Social Determinants of Health Interventions in Pediatric Primary Care	1
A Call for Consistent Measurement Across the Social Determinants of Health Industry Landscape	1
Accelerating Success in Value-Based Care and Population Health: Learnings from a High-Performing Physician Organization	1
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	1
Call for Special Issue Papers: Reducing Health Disparities in Underserved Populations	1
Certified Community Behavioral Health Clinic Demonstration Impact on Health Care Utilization Among Non-Medicaid Patients with Severe Mental Illnesses	1
Evaluation of a Clinical Platform to Promote Chronic Disease Management	1
Optimizing Vaginitis Diagnosis to Reduce Health Care Costs in Nonpregnant Women Utilizing Molecular Diagnostics	1
Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations	1
Comparing the Predictive Effects of Patient Medication Adherence Indices in Electronic Health Record and Claims-Based Risk Stratification Models	1
Collaboration Between Public Health and Marketing Experts as a Response to COVID-19	1
Leveraging Digital Medicine to Support Providers and Their Patients in Managing Serious Mental Illness	1
Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	1
Full-Risk Population Health Programs for Older Adults Like PACE Benefit from COVID-19	1
Costs of Two Health Insurance Plan Programs to Mail Fecal Immunochemical Tests to Medicare and Medicaid Plan Members	1
Design and Framework of a Technology-Based Closed-Loop Referral Project for Care Coordination of Social Determinants of Health	1
Trends and Patterns of Social History Data Collection Within an Electronic Health Record	1
Implementation of High-Quality Lung Cancer Screening: Impact of Centralized vs. Decentralized Processes	1
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	1
Review of “Re-Engaging in Trust: The Missing Ingredient to Fixing Healthcare”	1
Disparities in Emergency Department Visits for Opioid and Stimulant Overdoses in Florida During COVID-19	1
The Physician’s Role in Countering Medical Misinformation Through Advocacy	1
County-Level Concentration of Selected Chronic Conditions Among Medicare Fee-for-Service Beneficiaries and Its Association with Medicare Spending in the United States, 2017	1
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	1
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	1
Redesigning Kidney Disease Care to Improve Value Delivery	1
Diagnostic Testing of Vaginitis: Improving the Value of Care	1
For Profit, but Socially Determined: The Rise of the SDOH Industry	1
Differences in Persistently Elevated Hemoglobin A1c for African American and White Patients and the Role of Provider-Level Variation	1
Electronic Health Record-Based Risk Stratification: A Potential Key Ingredient to Achieving Value-Based Care	1
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	1
Social Intervention by the Numbers: Evidence Behind the Specific Public Health Guidelines in the COVID-19 Pandemic	1
Centering Providers to Deliver Group Care: Implementing CenteringPregnancy and CenteringParenting at an Urban Federally Qualified Health Center	1
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	1
Rural, Underserved, and Minority Populations' Perceptions of COVID-19 Information, Testing, and Vaccination: Report from a Southern State	1