Problem 1: We have discussed both high-risk population approaches and population-based "shift the curve" approaches. Why do you think healthcare providers frequently implement high-risk population approaches instead of "shift the curve" approaches?
Problem 2: Why would having a behavioral health condition in addition to having a chronic health condition exclude patients from being identified as low-risk?
Problem 3: Use the Places Interactive Map to describe significant measures of community health (use all three of the health outcomes, prevention, and unhealthy behaviors) for East Point, Georgia. How does the East Point community compare to the entire county of Fulton? How does Fulton County compare to the county where you live? You can use the Places County Compare Report to easily find county-level measures.
Problem 4: Given the health conditions in the high-risk group, what are Triple Aim outcome measures that should be evaluated for this population? Please provide at least two measures per Triple Aim domain and justify why you selected these measures. It would be very helpful to review the MIPS quality measures for health conditions that are relevant to the high-risk group.
Problem 5: The patient intervention included: one clinic visit with the PCP, four home visits with a CHW and behavioral health assessments provided by the LCSW. Clearly, the majority of services provided to patients are not given by the PCP. Justify the reasoning for this approach based on what we have learned about health determinants.