Reference no: EM133374345

Develop a Population Health Management (PHM) approach addressing group of patients with Type 2 Diabetes:

Identification of Patients - Describe how you would identify the population of patients that the program is intended to address (e.g., medical records, lab results, medical claims). [Please note that a single approach alone may not identify all of the population at risk. For example, if you want to identify depressed patients and rely upon a physician diagnosis in the medical records, many patients with depression are not accurately diagnosed in primary care. In that case a screening measure such as the PHQ-9 for depression may be needed in addition to medical records.]

Risk Stratification of Patients - Describe how you would divide the patient population based upon levels of acuity, social determinants of health, and health disparities (e.g., PHQ-9 scores may be used to classify patients into low, medium, and high severity based on the total score).

Communication and Intervention - Describe how you would outreach for patient engagement, conduct initial screenings, and the criteria used to identify the need to perform additional assessments.

Culturally-Competent Patient Engagement - Describe how you would address relevant cultural issues while connecting the patients to established programs and services.

Stepped Care Intervention - Describe one evidence-based intervention treatment approach and how you would use that intervention to address each subgroup within the stratified patient population.

Measurement and Follow-Up - Describe how you would measure changes in associated medical, behavioral health, and lifestyle issues over time and the criteria that would inform follow-up visits.