Competency

Apply data analytic methodologies to diverse populations to address population health needs.

Scenario

You have assessed your local population health needs and identified data sources and data sets that are needed to help providers make immediate gains in patient outcomes. Your health systems Board of Directors is requesting that you develop a high-level population health management program dashboard.For this assessment, you need to assess local population health needs and identify data sources and data sets that are needed to help providers make immediate gains in patient outcomes. It is a major undertaking to plan, design, and implement a robust PHM. Therefore, your health systems Board of Directors is requesting that you develop 1-2 page high-level population health management program dashboard. In this dashboard, list the health needs based on the community needs assessment and the critical data sources and data sets needed for the population health management program your health system is planning to launch.

Instructions

Using the information from the modules 01, 02, and 03 summative assessments, construct a dashboard that lists the health needs based on the community needs assessment that was performed and the critical data sources and data sets needed for the population health management program your health system is planning to launch.

Resources

Below is a list of resources that you can review to learn more about how to construct an executive dashboard.Byrnes, J. (2012).

Driving value: solving the issue of data overload with an executive dashboard

. Healthcare Financial Management: Journal Of The Healthcare Financial Management Association, 66(10), 116.Ballou, B., Heitger, D. L., & Donnell, L. (2010).

Creating effective dashboards

. Strategic Finance, 91(9), 27-32Ghazisaeidi, M., Safdari, R., Torabi, M., Mirzaee, M., Farzi, J., & Goodini, A. (2015).

Development of performance dashboards in healthcare sector: Key practical issues

. Acta Informatica Medica, 23(5), 317-321.Rosow, E., Adam, J., Coulombe, K., Race, K., & Anderson, R. (2003).

Virtual instrumentation and real-time executive dashboards. Solutions for health care systems

. Nursing Administration Quarterly, 27(1), 58-76.

Healthcare Dashboards: 3 Keys for Creating Effective and Insightful Executive Dashboards

Executive Dashboards: What They Are And Why Every Business Needs One

6 examples of executive dashboards that wow the “C” suite

Running head: BIG DATA IN DIABETES MANAGEMNT

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BIG DATA IN DIABETES MANAGEMENT

Big Data in Diabete

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Management

Student’s Name

Institutional Affiliation

Many organizations use data for the purpose of data analytics. However, before organizations can get valuable information about big data, they may need knowledge of various significant data sources. As a PHM program leader, I would focus on diabetes management and find out the significant data sources used to analyze patients who have diabetes. Examples of substantial data sources include the media, cloud, the web, IoT, and databases (Russom, 2011). The different sources of big data are aimed at providing data for purposes of customer analytics, industrial analytics, business process analytics, and analytics for fraud detection. In our case, healthcare information can be found in many sources throughout the web.

The best big data that may use in diabetes management would be artificial intelligence and IoT. Digital health takes into account advanced medical technologies and digital communication (Al-Turjman, 2019). Machine learning enables us to take into account the identification, prediction of patterns, and inductive reasoning. Today, diabetes management is facing a whole lot of challenges, including the decreased number of diabetologists and an increase in the number of patients (Eswari, Sampath, & Lavanya, 2015). With the use of artificial intelligence, diabetologists can take full responsibility for their patients (Ross, Anderson, Kodate, Thompson, Cox, & Malik, 2014). Robust data analysis will ensure that gaps in care are identified, and the necessary measures are taken to mitigate risks.

Less digital ways of acquiring patient information in the past included ADT alerts, demographics, and ICD-10 codes (Nyenwe, Ashby, Tidwell, Nouer, & Kitabchi, 2011). Although there are effective ways, they may not provide varied data on patients with diabetes. They also do not help in proper analysis, and therefore integrating artificial intelligence and IoT may help in obtaining and analyzing big data for diabetes patients.

References

Al-Turjman, F. (Ed.). (2019). Artificial Intelligence in IoT. Springer.

Eswari, T., Sampath, P., & Lavanya, S. (2015). Predictive methodology for diabetic data analysis in big data. Procedia Computer Science, 50, 203-208.

Nyenwe, E. A., Ashby, S., Tidwell, J., Nouer, S. S., & Kitabchi, A. E. (2011). Improving diabetes care via telemedicine: Lessons from the Addressing Diabetes in Tennessee (ADT) project. Diabetes Care, 34(3), e34-e34.

Ross, A. J., Anderson, J. E., Kodate, N., Thompson, K., Cox, A., & Malik, R. (2014). Inpatient diabetes care: complexity, resilience and quality of care. Cognition, technology & work, 16(1), 91-102.

Russom, P. (2011). Big data analytics. TDWI best practices report, fourth quarter, 19(4), 1-34.

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Running head: Assessing Data Sets for Population Health Management 1

Assessing Data Sets for Population Health Management

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Assessing Data Sets for Population Health Management

Kimberly Huff

Rasmussen College

Author Note

Deliverable 2 Submitted January 19, 2021

Data Sets

Data sets are an important component when conducting many different forms of research. Collecting data allows one to examine the information from different elements. After data is collected it could be manipulated when needed using a computer. In previous times patient information was recorded using the pen and paper method. Using computer methods today allow for ease of access.

Increasing the quality of care is at the forefront of many healthcare organizations. With that said, medical data serves as an essential component where the quality of care is concerned. The majority of data comes from the patient. Patients can supply data that lead healthcare workers to develop patient-specific ways to prevent diseases, personalize treatments, and enhance overall health outcomes. Healthcare data is also essential in the management and administration of the hospital or facility and makes it easier to track a patient’s medical trek. Data is also crucial in reducing or eliminating medical errors.

Population health management focuses on the improvement of the healthcare delivery system within a specified area. To determine appropriate measures to take the data must be current and accurate. Different information to include in the data sets that can be utilized are socioeconomic determinants and electronic health records.

Socioeconomic determinants will provide valuable information such as the level of education, occupation, and income of the people residing in a selected area. Once evaluated this type of information can aid in tracking prominent illness within the area. Using electronic medical records will aid in logging different illnesses/diseases and their outcomes. These data sets will be critical in allowing the health system PHM program in the selected area. The data sets will provide relevant information which will in turn be beneficial when organizing the PHM program.

Gathering personal information such as age, sex, and ethnicity, occupation, and income will be important as once analyzed it will allow one to determine if those factors influence disease and illness. Using the HER system will allow all participants to view the information as needed and offer the chance to gather additional information when needed. The data gathered should be checked for accuracy. Having accurate data will ensure the success of the program.

Gathering data from different sources will provide a broad range overview. Many areas are large such as Marion County so accurate data would be essential when determining ways to decrease illness and disease. Data within a PHM program is typically informed data so all data must be true and accurate in its entirety to be analyzed correctly.

Diabetes

Diabetes has become an issue for many people around the world. Diabetes is a condition that develops when blood sugar in the body rises above average, and this occurs when the pancreas fails to work as required. Many times diabetes can be controlled by diet and exercise. In some cases medication management would need to be utilized if diet and exercise fail. Promoting education is key to any health improvement plan. Relevant and adequate data is a requirement when researching disease and illness.

Data can be gathered within the community which include, number of individuals diagnosed with diabetes, age, race, ethnicity, comorbidities, socioeconomic status, and location of residence. Air pollution is the primary environmental factor contributing to diabetes, as it results in increased insulin resistance. Once this information is obtained, further analysis of the information can be completed to determine if there is a pattern of the disease.

Despite diabetes being a lifestyle condition, the disease develops because of various social factors, including poverty. Disadvantaged people may not be able to afford healthy foods, have inadequate access to prevention resources and healthcare management, increasing their susceptibility to diabetes. Also, low education. People with low education achievement have insufficient knowledge about the development and prevention of diabetes.

References

Dahl, S., & Brennhofer, S. (2018). PHM-Focused Healthcare Delivery. In S. Dahl, & S. Brennhofer, Training to Deliver Integrated Care (pp. 65-78). Cham: Springer.

Institute of Medicine (U.S.). (2012). Primary Care and Public Health : Exploring Integration to Improve Population Health. National Academies Press.

Marioncountyhealth.gov (2020). COMMUNITY HEALTH IMPROVEMENT PLAN.

2020_2024_community_health_improvement_plan_chip (floridahealth.gov)

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Mennis, J., & Stahler, G. (2016). Racial and ethnic disparities in outpatient substance use disorder treatment episode completion for different substances. Journal of substance abuse treatment, 63, 25-33.

Powell, P., D Corathers, S., Raymond, J., & Streisand, R. (2015). New approaches to providing individualized diabetes care in the 21st century. Current diabetes reviews, 11(4), 222-230. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4864491/

Rollins, L., Gordon, T. K., Proeller, A., Ross, T., Phillips, A., Ward, C., Hopkins, M., Burney, R., Bojonowski, W., Hoffman, L., Daniels, Y., Mobley, M., Mubasher, M., & Akintobi, T. H. (2020). Community-Based Strategies for Health Priority Setting and Action Planning. American Journal of Health Studies, 35(2), 102–114.

Community Needs Assessment

Marion County

Marion County Florida
Located in Central Florida with a population of 343, 778.

Marion county is in central Florida.
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Social Determinants
Factors included in this category, generational poverty, widespread homelessness, persistent issue of overweight and obesity, lack of affordable housing, shortage of healthcare and dental care providers, water fluoridation is lacking in most communities, struggling and failing schools, and built environment impedes access to recreation areas and safe places for physical activity.

Addressing social determinants of health is important for improving health and reducing health disparities.
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Marion County Most Utilized Hospitals

Hospital Name Number of Discharges
Florida Hospital Ocala 15,739
Ocala Regional Medical Center 8,940
West Marion Community 6,532

Medical Resources Available
Clinical and nutrition services
Wellness programs
Environmental health
Infectious Disease services

Clinical and nutrition services include – Supplements for women and children, immunizations throughout various locations within the county, dental services, family planning, and centers which treat sexually transmitted diseases.
Wellness programs which include – disease prevention and management such as diabetes. Weight programs, children healthy promotional programs, and health education.
Environmental health which includes – Environmental Health programs are essential to public health. They work to achieve a safe and healthy environment for the community. Environmental Health staff monitor conditions that could present a threat to health and safety of the public.
Infectious Disease services which involves, The Florida Department of Health in Marion County is responsible for the surveillance of reportable communicable diseases, including enteric diseases, vaccine-preventable diseases, invasive bacterial diseases, arthropod-borne diseases, and others. Infectious disease control programs are designed to protect the residents and visitors of Marion County
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Community Needs Assessment
Marion County community needs include, access to primary prevention and healthcare, oral health, mental and behavioral health, education and training.

Primary prevention efforts are focused on preventing illness and injury before it happens. Prevention includes environmental and policy change as well as education, behavior revision and lasting investments in systems that encourage healthy living.
Oral health influences physical, emotional, and social well-being. Poor oral health causes pain and disability. With pain and disability hinders work and school which causes issues with attendance and performance. Oral issues will in turn costs residents, taxpayers and healthcare systems millions of dollars to treat.
Mental and physical health are equally important factors for overall health and quality of life. Mental and behavior health includes emotional, psychological and social well-being and impacts how stress is handled, interpersonal relationships, and healthy decision-making.
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Priority Concerns
Access to Primary Prevention
Oral Health
Mental and Behavioral Health

Access to Primary Prevention and Health Care Services with focus on, Community wellness and Access to primary care.
Oral Health including, Access to oral health services and Expansion of prevention initiatives
Mental and Behavioral Health including, Access to care for mental health conditions and substance abuse treatment services
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Steps to improvement
Promote Community Wellness
Improve Access to Primary Care
Improve Access to Oral Health Services
Improve Oral Health Through Expansion of Prevention Initiatives

Community Wellness
Decrease tobacco access, increase educational opportunities in middle schools, and increase treatment in high schools. Reduce the number of middle school and high school students who used cigarettes, cigars, smokeless tobacco, or electronic vapor products.

Increase access to healthy affordable foods within food deserts, increase education on healthy eating options and increase participation in physical activity, reduce the Marion County middle and high school obesity rate.
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Access to Primary Care
Increase the number of individuals using free clinics, reduce the uninsured rates, and increase the number of services provided. Decrease the number of adults who could not see a doctor in the past year due to cost.

Increase Medicaid providers who will see high risk pregnancies and provide resource guide to pregnant women, and decrease the number of women receiving late or no prenatal care.
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Access to Oral Health Care
Increase mobile and portable clinic dental availability in high risk neighborhoods, increase evening and weekend dental appointment availability, and strengthen referral system. Reduce the oral health emergency department visit rate. Increase the percentage of adults who have visited a dentist or dental clinic.

Prevention Initiatives
Education to water system operators on funding available to add fluoridation to water systems and increase the percentage of Marion County population receiving optimally fluoridated water.

Performance Indicators
Performance indicators used include:
Number of individuals that have established a primary care physician.
Amount of those individuals who have decreased risk factors associated with chronic illnesses from the result of seeking primary prevention.  
Increased percentage of adults who have visited or received services for oral care.
Decreased percentage of oral health emergency department visit rate.
Percentage of individuals within the county who have fluoridated water

Performance indicators are used as a form of measurement to demonstrate if goals are being achieved.
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References
FloridaHealth.gov (2021). Programs and Services. Https://floridahealth.gov
Institute of Medicine (U.S.). (2012). Primary Care and Public Health : Exploring Integration to Improve Population Health. National Academies Press.
Marioncountyhealth.gov (2020). COMMUNITY HEALTH IMPROVEMENT PLAN. 2020_2024_community_health_improvement_plan_chip (floridahealth.gov)
Rollins, L., Gordon, T. K., Proeller, A., Ross, T., Phillips, A., Ward, C., Hopkins, M., Burney, R., Bojonowski, W., Hoffman, L., Daniels, Y., Mobley, M., Mubasher, M., & Akintobi, T. H. (2020). Community-Based Strategies for Health Priority Setting and Action Planning. American Journal of Health Studies, 35(2), 102–114.
Wellglorida.ord (2020). County Health Profile: Marion County Data. Marion County Data |
WellFlorida.