Population Health Management

Article	Citations
A Theoretically Grounded Chronic Illness Model Integrating Medical- and Community-Based Social Service Providers	69
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	68
Association Between Social Vulnerability and Postoperative Complications and Readmission Among Cardiovascular Surgery Patients	48
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	30
Health Equity Is Key to Better Population Health	21
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	19
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	19
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	18
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	18
Chronic Care Management and Mortality Among Diabetic Patients with Multiple Chronic Conditions	15
Social Needs Screening in Academic Health Systems: A Landscape Assessment	15
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	15
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	14
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	14
Patient Engagement with General Bulk Outreach: Impact of Primary Care Provider vs. Care Team Signature in General Bulk Patient Outreach	14
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	13
Prior Authorization: Process Redesign with a Focus on Value-Based Care	13
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	12
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	12
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	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	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
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	11

Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	10
Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population	10
Factors Influencing Learners’ Knowledge and Implementation of Value-Based Care Concepts Postcourse Certification	10
Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates	9
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	9
Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations	9
What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study	9
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	9
Cost-Effectiveness of Screening and Early Diagnosis Strategies for Cancer in the General Adult Population in Low- and Middle-Income Countries: A Systematic Review	8
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	8
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	8
Reimagining Diabetes Quality Measurement to Advance Quality Care	8
A Review of the MINDSPACE Framework for Nudging Health Promotion During Early Stages of the COVID-19 Pandemic	7
What Is Old Needs to Be New Again	7
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	7
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	7
The Cost of Unhealthy Days: A New Value Assessment	7
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	6
Leveraging Technology for Value-Based Kidney Care	6
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	6
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	6
Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach	6
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	6
Implementation and Outcomes from a Post-Discharge Intervention Program in a Medicare ACO Population	6
Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities	6
Correction to : Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities, by Laura B. Beidler, et al. Popul Hea	5
Mental Health Service Use and Equity in a Comprehensive Employer-Sponsored Benefit Program: A Retrospective Cohort Study	5
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	5
What Is a Center of Excellence?	5
Cost Reduction and Utilization Patterns in a Medicare Accountable Care Organization Using Home-Based Palliative Care Services	5
Addressing Social Determinants of Health in Family Medicine Practices	5
The Role of Social Determinants of Health in Gastroenterology Care	5
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	5
The Academic Payvider Model: Commentary	5
The Future of Population Health	5
The Future of Chronic Disease Management	4
Implementation of E-Consults in an Integrated Health System for a Value Population	4
Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	4
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	4
Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	4
For Profit, but Socially Determined: The Rise of the SDOH Industry	4
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	4
Acknowledgment of Reviewers 2025	4
Honoring the Past While Shaping the Future: Reflections From the Incoming Editor-in-Chief	4
Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change	4
Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	4
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	3
The Impact of Expanding Telehealth-Delivered Dietary Interventions on Long-Term Cardiometabolic Health	3
The Impact of Social Vulnerability and Race on Colorectal Cancer Screening	3
Rethinking Blood Pressure Quality Measurement: Accounting for Seasonal Variation in Value-Based Care	3

Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak	3
Feasibility of an Adaptive Food Insecurity Intervention for Patients with Uncontrolled Hypertension: A Pilot SMART	3
Letter to the Editor: Public Health Reform Efforts Should More Effectively Engage Public Health Professionals and the General Public	3
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	3
A Path to Risk: Critical Elements of a Structured Approach	3
Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities	3
The Impact of Public Health Funding on Population Health Outcomes	3
Molecular Testing for Women’s Gynecologic Health: Real-World Impact on Health Care Costs	3
Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems	3
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	3
The Unfortunate State of Population Health: Its Omnipresent Promise and Industry's Continued Failure of Vision and Commitment	3
Hospital-at-Home: The Good, the Bad, and the Ugly	3
Health Care Bricolage: A Method to Reduce High-Cost Medical Spend	3
Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population	3
Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis	2
Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review	2
Enhancing Machine Learning Explainability of Disaster Preparedness Models from the FEMA National Household Survey to Inform Tailored Population Health Interventions	2
A Call to Action to Increase Uptake of Follow-Up Colonoscopy After Initial Positive Stool-Based Colorectal Cancer Screening	2
Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes	2
Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial	2
Health Care Professionals' Perspectives on Universal Screening of Social Determinants of Health: A Mixed-Methods Study	2
The Unrecognized Impact of Anxiety in Complex and Costly Patients	2
Future Trends to Watch for Value-Based Care	2
Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care	2
From Patient Goals to Team Action: A Qualitative Analysis of Student Capstone Projects from a Complex Care Curriculum	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
AI and Falls Detection: Great Promise but Gaps in Evidence	2
Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives	2
Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care	2
Electronic Health Data Quality and Population Health Management Algorithms	2
Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies	2
The Clinical and Economic Burdens of Obesity and the Value of Weight Loss for an EMR-Derived US Cohort: A Modeling Study	2
It Is Time to Supersize Our Population Health Improvement Goals	2
A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population	2
Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis	2
Social Determinants of Health and After-Hours Electronic Health Record Documentation: A National Survey of US Physicians	2
The Key to Success Tomorrow Is Leadership Transformation Today	2
Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models	2
Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures	2
The Academic Payvider Model: Care and Coverage	2
Comparing Clinician Impression of Cognition with Standardized Screening in Medicare Annual Wellness Visits	2
Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California	2
Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention	2
Cervical Cancer and Sexually Transmitted Infections Screening Among Individuals with a Substance Use Disorder: A Retrospective Cohort Study	2
Social Determinants of Hepatitis C Virus Infection in the United States, 2016–2021	2
Composite Indices of Social Determinants of Health: Overview, Measurement Gaps, and Research Priorities for Health Equity	2
Opportunities and Challenges in Screening for Colorectal Cancer	2
Employer Strategies for Health Care Price Transparency	1
Building for Value: A Foundational Structure to Support Population Health	1
Application of Narrative Nursing Combined with Psychological Resilience Training in Patients and Their Families in Hospice Care	1
A Call for an American Social Care System: Social Services Reimbursement to Address Fragmented Care	1
A Call for Consistent Measurement Across the Social Determinants of Health Industry Landscape	1
Factors Associated with Chronic Disease and Health Care Utilization Among Young Adults in South Korea	1
Rural, Underserved, and Minority Populations' Perceptions of COVID-19 Information, Testing, and Vaccination: Report from a Southern State	1
Pediatric Population Management Classification for Children with Medical Complexity	1
Hospital Outcomes for Patients with Psychiatric Comorbidities: A Comparison of an Integrated Medical-Psychiatry Unit and Traditional Medical Units	1
Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort	1
Accelerating Success in Value-Based Care and Population Health: Learnings from a High-Performing Physician Organization	1
Gun Violence Prevention Policies Are Not Political: They Are Just Part of Good Public Health	1
Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis	1
Z Codes for Social Determinants of Health: A Better Predictor of Risk for Value-Based Care	1
Disparities in Recombinant Zoster Vaccine Coverage in the United States	1
Association Between Relative Fat Mass and New-Onset Arthritis Among Middle-Aged and Older Chinese Females	1
Impact and Continued Relevance of Medication Adherence Measurement	1
Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity	1
Put All Your Health Investments Under the Same Lens	1
Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations	1
A Comparison of Emergency Room Visits and Hospital Admissions Between People with Prediabetes and Diabetes	1
Adopting Health Technologies in Israel and England	1
To Win We Must Change the Game: A Formula for Health Care Transformation	1
Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study	1
Comparing “Meaningful Use” of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties	1
Health Systems Need to Transform Data Collection to Advance Health Equity	1
Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice	1
Predictors of Interest in Offered Social Care Assistance Among People with Uncontrolled Diabetes	1
Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah	1
Do Refill Gaps Indicate Nonadherence? A Perspective on the Medication Adherence Metric for Quality Rating of Medicare Advantage Plans	1
Trends in Mental Health Utilization Before and During the COVID-19 Pandemic: Federally Qualified Health Centers As a Case Study	1
Chart Review Is Dead; Long Live Chart Review: How Artificial Intelligence Will Make Human Review of Medical Records Obsolete, One Day	1
The Coming Health Care Transformation: Empowered Patients and Better Value	1

Future Role of the Clinical Lab in Population Health	1
Development of Digital Algorithms for the Early Identification of Rare Clinical Outcomes Using Electronic Medical Records: A Case Study of Hidradenitis Suppurativa	1
Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups	1
Postpartum Medicaid Coverage Expansion and Changes in the Risk of Health Insurance Loss Within the Second Year After Birth	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
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	1
Lessons Learned from the Camden Coalition's Work with High Needs, High Complexity Patients	1
Population Health: Staying Focused through the Pandemic and Beyond	1
Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population	1
Global Challenges with Oral Antivirals for COVID-19	1
Chronic Kidney Disease, Diabetes, and Population Health: From Primary Care to Transplant	1
Progression to the Mean: Reconciling Traditional and Modern Professional Values in Medicine	1
Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities	1
Evolution of Population Health Within US Schools of Medicine and Academic Medical Centers	1
Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations	1
Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island	1
A Multi-Intervention Approach to Blood Pressure Control: A Description of How a Large University Based Primary Care Clinic Tackled Hypertension	1
Evaluation of the Electronic Health Record-Support Social Support Score in Breast Cancer: Comparison of Count and Item Response Theory Scores	1
Impact of Income Disparity on Utilization of Home-Based Care Services Among Older Adults in Japan: A Retrospective Cohort Study	1
Reflections on the Connection Between Health Care Quality and Population Health	1
Redesigning Diabetes Care for Treatment Inertia: A Population Health Model	1