Population Health Management

Article	Citations
One Year Out: The Five Ds of COVID-19	65
Improve Patient-Centered Care, Decrease Provider Burnout, Maximize Z Codes, Minimize Hierarchical Condition Category Codes	60
Examining the Association of Social Needs with Future Health Care Utilization in an Older Adult Population: Which Needs Are Most Important?	47
A Population Health Proposal for Increasing Breast Cancer Screening to Reduce Racial Disparities in Breast Cancer: Getting the Village Back Together	41
More Patient Data? Be Careful What You Wish for…AI’s Role in Making Clinical Data Exchange Useful	37
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	25
COVID-19 Vaccination, Morbidity, and Mortality During a 12-Month Period in Israel: Can We Maintain a “Herd Immunity” State?	24
Health Equity Is Key to Better Population Health	20
Evaluation of the Impact of Discharge Clinic Follow-Up Interventions on 30-Day Readmission Rates	18
Social Needs Screening in Academic Health Systems: A Landscape Assessment	17
Letter to the Editor: Pivoting Care Coordination Efforts Based on Risk and Return	16
Optimizing Hierarchical Condition Category-Risk Adjustment Factor Management in Population Health Using Rapid Process Improvement Methods	16
A Tale of 4 Babies: Health Equity at the Center of the Quadruple Aim	16
Patient Engagement with General Bulk Outreach: Impact of Primary Care Provider vs. Care Team Signature in General Bulk Patient Outreach	16
Perceived Stigma in Health Care Settings Mediates the Relationships Between Depression, Diabetes, and Hypertension	16
The Impact of the Affordable Care Act on Disparities in Utilization of Cardiovascular Preventive Services by Socioeconomic Status	15
Medicaid Acceptance Varies by Physician Seniority and Specialty in California	14
Prior Authorization: Process Redesign with a Focus on Value-Based Care	14
COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition	14
Cost-Effectiveness of Outreach Strategies for Stool-Based Colorectal Cancer Screening in a Medicaid Population	13
Ambulatory Care Utilization Among Medicare Beneficiaries with Depression	13
Factors Influencing Learners’ Knowledge and Implementation of Value-Based Care Concepts Postcourse Certification	11
What Are the Roles of Community Health Workers in Medicaid Managed Care? Results from a National Study	11
Transitional Care for Older Adults: Demonstration of the Role of a Partnership Payvider	11
COVID-19 Vaccine Equity: Codesigning Public Health Interventions with Community Partners	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	10
Successful Implementation of an All-or-None Diabetes Measure in 10 US Health Systems	10
A Conceptual Framework for Building Individual and Team Capabilities to Provide Effective Longitudinal, Relationship-Based Clinical Case Management	10
The Impact of Personal and Historical Factors That Contribute to Medicare Readmissions	10
Impact of COVID-19 on Behavioral Health Services Use Among Medicaid Enrollees with Chronic Behavioral Needs by Race and Ethnicity	10
Innovations in Population Health: Improving Outcomes for Patients with Chronic Kidney Disease	10
Bridging the Digital Divide: A Practical Roadmap for Deploying Medical Artificial Intelligence Technologies in Low-Resource Settings	9
The Cost of Unhealthy Days: A New Value Assessment	9
Use of a Blood Biomarker Test Improves Economic Utility in the Evaluation of Older Patients Presenting with Cognitive Impairment	9
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	9
Using Quality Measures to Drive Improvements in Immunization Rates: Findings from a Real-World Evaluation from 3 US Health Care Organizations	9
Enhanced Primary Care for Severe Mental Illness Reduces Inpatient Admission and Emergency Room Utilization Rates	9
Reimagining Diabetes Quality Measurement to Advance Quality Care	9
Increasing Statin-Prescribing and Low-Density Lipoprotein Cholesterol Control in Secondary Atherosclerotic Cardiovascular Disease Prevention: A Collaborative Approach	8
Limitations to Health Care Quality Measurement: Assessing Hospital Variation in Risk of Cardiac Events After Noncardiac Surgery	8
Engaging Stakeholder Advisors Around Health-Related Social Needs Research, Policy, and Practice Priorities	8
Interventions to Increase Affordable Care Act Marketplace Enrollment: A Systematic Review and Meta-Analysis	8
Individual- and Community-Level Predictors of Hospital-at-Home Outcomes	8
Reducing Health Disparities in Underserved Populations: A Spotlight on Health Inequities	7
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
Cost-Effectiveness of Screening and Early Diagnosis Strategies for Cancer in the General Adult Population in Low- and Middle-Income Countries: A Systematic Review	7
Leveraging Technology for Value-Based Kidney Care	7
Transitioning from In-Person to Telemedicine Within Primary Care Behavioral Health During COVID-19	6
Health Inequality Among Older Adults with Percutaneous Coronary Intervention and Universal Health Coverage in Japan	6
Health Resources and Services Administration-Funded Health Centers Reduce Health Care Expenditures of California Medicaid Managed Care Beneficiaries with Complex Needs	6
What Is a Center of Excellence?	6
The Role of Social Determinants of Health in Gastroenterology Care	6
Assessing the Added Value of Blood Pressure Information Derived from Electronic Health Records in Predicting Health Care Cost and Utilization	6
Medicaid Cost Savings from Provision of Contraception to Beneficiaries in South Carolina, 2012–2018	6
Correction to : Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities, by Laura B. Beidler, et al. Popul Hea	6
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
Multisector Partnerships and Service Colocation to Increase Adoption of Influenza Vaccines and Address Food Insecurity	5
The Future of Chronic Disease Management	5
Implementation of E-Consults in an Integrated Health System for a Value Population	5
The Future of Population Health	5
The Academic Payvider Model: Commentary	5
For Profit, but Socially Determined: The Rise of the SDOH Industry	5
Challenge of Managing Chronic Kidney Disease: Patient and Caregiver Perspectives	5
An Increase in the Use of ICD-10 Z-Codes for Social Risks and Social Needs: 2015 to 2019	5
Evidence and Implications of the Affordable Care Act for Racial/Ethnic Disparities in Diabetes Health During and Beyond the Pandemic	5
Major Economic Losses Associated with Inadequate Control of High Blood Pressure: Time for a Major Change	5
Honoring the Past While Shaping the Future: Reflections From the Incoming Editor-in-Chief	5
A Path to Risk: Critical Elements of a Structured Approach	4
Hospital Safety-Net Burden is Associated with Perioperative Outcomes in Primary Total Hip Arthroplasty: A Multistate Retrospective Analysis, 2015–2020	4
The Minority and Rural Coronavirus Insights Study: Design and Baseline Characteristics of a Minority Cohort	4
Systematic Review of Care Coordination Interventions Linking Health and Social Services for High-Utilizing Patient Populations	4
The Impact of Expanding Telehealth-Delivered Dietary Interventions on Long-Term Cardiometabolic Health	4
Estimating Cost Savings of Care Coordination for Older Adults: Evidence from the Iowa Return to Community Program	4

Assessing the Relationship Between Behavioral Health Integration and Alcohol-Related Treatment Among Patients with Medicaid	4
Sickle Cell Disease in an Older Adult Population: A Retrospective Review of Health Care Resource Utilization	4
Addressing Social Needs in Clinical Settings: Early Lessons from Accountable Health Communities	4
Reimagining Our Public Health Systems: The Robert Wood Johnson Foundation's National Commission to Transform Public Health Data Systems	4
Developing a Strategy to Increase Lung Cancer Screening in Areas of Need	4
Social Determinants of Health and Comorbidities Among Individuals with Atherosclerotic Cardiovascular Disease: The Behavioral Risk Factor Surveillance System Survey	4
The Impact of Public Health Funding on Population Health Outcomes	4
Hospital-at-Home: The Good, the Bad, and the Ugly	4
Impact of Health Literacy on Medication Adherence Among Black Medicaid Beneficiaries with Hypertension in Delaware: A Cross-Sectional Study	4
Electronic Health Data Quality and Population Health Management Algorithms	3
Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies	3
The Clinical and Economic Burdens of Obesity and the Value of Weight Loss for an EMR-Derived US Cohort: A Modeling Study	3
Composite Indices of Social Determinants of Health: Overview, Measurement Gaps, and Research Priorities for Health Equity	3
Letter to the Editor: Public Health Reform Efforts Should More Effectively Engage Public Health Professionals and the General Public	3
Future Trends to Watch for Value-Based Care	3
Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California	3
A Longitudinal, Relationship-Based Model for Managing Complex Chronic Disease in the Medicaid Population	3
Interprofessional Intervention to Reduce Emergency Department Visits in Black Individuals with Diabetes	3
The Unrecognized Impact of Anxiety in Complex and Costly Patients	3
Social Determinants of Hepatitis C Virus Infection in the United States, 2016–2021	3
Tackling Ethnic Health Disparities Through Community Health Worker Programs: A Scoping Review on Their Utilization During the COVID-19 Outbreak	3
It Is Time to Supersize Our Population Health Improvement Goals	3
Racial and Ethnic Disparity in Preference-Weighted Quality of Life: Findings from the Selenium and Vitamin E Cancer Prevention Trial	3
Stratifying for Value: An Updated Population Health Risk Stratification Approach	3
Data-Driven Leadership: Clinical Registries Drive Higher Value Health Care	3
Opportunities and Challenges in Screening for Colorectal Cancer	3
Assessing Barriers and Facilitators to Lung Cancer Screening: Initial Findings from a Patient Navigation Intervention	3
Molecular Testing for Women’s Gynecologic Health: Real-World Impact on Health Care Costs	3
Health Care Bricolage: A Method to Reduce High-Cost Medical Spend	3
The Unfortunate State of Population Health: Its Omnipresent Promise and Industry's Continued Failure of Vision and Commitment	3
Racial Disparities in Cardiovascular Health Among the Acute Coronary Syndrome Population	3
Feasibility of an Adaptive Food Insecurity Intervention for Patients with Uncontrolled Hypertension: A Pilot SMART	3
Health Care Professionals' Perspectives on Universal Screening of Social Determinants of Health: A Mixed-Methods 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
Global Challenges with Oral Antivirals for COVID-19	2
Rural, Underserved, and Minority Populations' Perceptions of COVID-19 Information, Testing, and Vaccination: Report from a Southern State	2
Postpartum Medicaid Eligibility Expansions and Postpartum Health Measures	2
Hospital Outcomes for Patients with Psychiatric Comorbidities: A Comparison of an Integrated Medical-Psychiatry Unit and Traditional Medical Units	2
Community Coalitions' Perspectives on Engaging with Hospitals in Ohio to Address the Opioid Crisis	2
Enhancing Machine Learning Explainability of Disaster Preparedness Models from the FEMA National Household Survey to Inform Tailored Population Health Interventions	2
Redesign of US Medical Schools: A Shift from Health Service to Population Health Management	2
Did the Affordable Care Act Promote Racial Equity in Pregnancy-Related Health? A Scoping Review	2
Validating and Improving Adjusted Clinical Group's Future Hospitalization and High-Cost Prediction Models for Dutch Primary Care	2
Perspectives on Obesity Management and the Use of Anti-Obesity Medicine from US Employees and Employers: Results from the OBSERVE Study	2
A Call for Consistent Measurement Across the Social Determinants of Health Industry Landscape	2
Progression to the Mean: Reconciling Traditional and Modern Professional Values in Medicine	2
Social Determinants of Health and After-Hours Electronic Health Record Documentation: A National Survey of US Physicians	2
Avoidance of Total Knee Replacement in a Population Health Setting: Introducing a Noninvasive Biomechanical Intervention for Patients with Knee Osteoarthritis	2
Measuring Stakeholder Engagement in Statewide Primary Care Cardiovascular Health Improvement Cooperatives	2
Implementation of Diabetes Prevention in Health Care Organizations: Best Practice Recommendations	2
The Key to Success Tomorrow Is Leadership Transformation Today	2
A Call to Action to Increase Uptake of Follow-Up Colonoscopy After Initial Positive Stool-Based Colorectal Cancer Screening	2
Estimating Eligibility for Lung Cancer Screening by Neighborhood in Philadelphia Using Previous and Current USPSTF Guidelines	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
From Patient Goals to Team Action: A Qualitative Analysis of Student Capstone Projects from a Complex Care Curriculum	2
Association of Unmet Social Needs with Chronic Illness: A Cross-Sectional Study	2
Factors Associated with Health Care Costs in Older Adults with Type 2 Diabetes: Insights for Value-Based Payment Models	2
AI and Falls Detection: Great Promise but Gaps in Evidence	2
The Academic Payvider Model: Care and Coverage	2
Gun Violence Prevention Policies Are Not Political: They Are Just Part of Good Public Health	1
Accelerating Success in Value-Based Care and Population Health: Learnings from a High-Performing Physician Organization	1
Health Care Utilization and Medicaid Spending in Children with Type 1 Diabetes in the Alabama Medicaid Program	1
Differences in Health Care Utilization for Asthma by Children with Medicaid versus Private Insurance	1
Chronic Kidney Disease, Diabetes, and Population Health: From Primary Care to Transplant	1
Changes in Health Care Utilization During the First 2 Years of Massachusetts Medicaid Accountable Care Organizations	1
Chart Review Is Dead; Long Live Chart Review: How Artificial Intelligence Will Make Human Review of Medical Records Obsolete, One Day	1
Employer Strategies for Health Care Price Transparency	1
Factors Associated with Chronic Disease and Health Care Utilization Among Young Adults in South Korea	1
Evaluation of the Electronic Health Record-Support Social Support Score in Breast Cancer: Comparison of Count and Item Response Theory Scores	1
System-Level Variation in Multiple Sclerosis Care Outcomes: Initial Findings from the Multiple Sclerosis Continuous Quality Improvement Research Collaborative	1
Pediatric Population Management Classification for Children with Medical Complexity	1
Lessons Learned from the Camden Coalition's Work with High Needs, High Complexity Patients	1
Comparing “Meaningful Use” of Health Information Technology in Pennsylvania: Electronic Prescription Rates of Metropolitan and Rural Counties	1
Predictors of Interest in Offered Social Care Assistance Among People with Uncontrolled Diabetes	1
Reckoning with Our Trustworthiness, Leveraging Community Engagement	1
To Win We Must Change the Game: A Formula for Health Care Transformation	1
A Payer–Provider Partnership for Endocrine Targeted Automatic eConsults: Implementation and Early Impact on Diabetes and Cost Outcomes	1
Strengthening the Public Health Partnership and Telehealth Infrastructure to Reduce Health Care Disparities	1
Relationship Between Socioeconomic Deprivation and Healthy Days Among Commercially Insured Adults Using a Digital Health Application: An Observational Study	1
Z Codes for Social Determinants of Health: A Better Predictor of Risk for Value-Based Care	1

New Drugs for Obesity, Is the Excitement Affordable?	1
Profiling Social Needs Activities in Publicly Traded Medicare Advantage Organizations	1
Put All Your Health Investments Under the Same Lens	1
Impact and Continued Relevance of Medication Adherence Measurement	1
Disparities in Recombinant Zoster Vaccine Coverage in the United States	1
Mobile Medical Clinics in the United States Post-Affordable Care Act: An Integrative Review	1
Development of Digital Algorithms for the Early Identification of Rare Clinical Outcomes Using Electronic Medical Records: A Case Study of Hidradenitis Suppurativa	1
Collateral Damage from the COVID-19 Pandemic: Pediatric Obesity	1
Redesigning Diabetes Care for Treatment Inertia: A Population Health Model	1
Characteristics of Nonelderly Adult Health Care Persistent Super Utilizers in Utah	1
Population Health: Staying Focused through the Pandemic and Beyond	1
Impact of Income Disparity on Utilization of Home-Based Care Services Among Older Adults in Japan: A Retrospective Cohort Study	1
A Comparison of Emergency Room Visits and Hospital Admissions Between People with Prediabetes and Diabetes	1
Trends in Mental Health Utilization Before and During the COVID-19 Pandemic: Federally Qualified Health Centers As a Case Study	1
Evolution of Population Health Within US Schools of Medicine and Academic Medical Centers	1
Exploring the Relationship Between Local Governmental Spending on the Social Determinants of Health and Health Care Costs of Privately Insured Adults	1
Permanent Supportive Housing Tenure Among a Heterogeneous Population of Adults with Disabilities	1
Cumulative Social Disadvantage and All-Cause Mortality in the United States: Findings from a National Study	1
Reflections on the Connection Between Health Care Quality and Population Health	1
Rosalind Franklin Society Proudly Announces the 2023 Award Recipient for Population Health Management	1
The Coming Health Care Transformation: Empowered Patients and Better Value	1
Do Refill Gaps Indicate Nonadherence? A Perspective on the Medication Adherence Metric for Quality Rating of Medicare Advantage Plans	1
Domain Knowledge, Digital Interactions, and Analytics: A Multifaceted Approach to Developing a Population Health Program	1
Accountable Care Organizations and Health Disparities of Rural Latinos: A Longitudinal Analysis	1
Future Role of the Clinical Lab in Population Health	1
Adopting Health Technologies in Israel and England	1
A Multi-Intervention Approach to Blood Pressure Control: A Description of How a Large University Based Primary Care Clinic Tackled Hypertension	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
Postpartum Medicaid Coverage Expansion and Changes in the Risk of Health Insurance Loss Within the Second Year After Birth	1
SARS-CoV-2 Outcomes: The Role of Patient Characteristics and Chronic Disease Comorbidities	1
Elective Joint Replacement Among Medicaid Beneficiaries: Utilization and Postoperative Adverse Events by Racial and Ethnic Groups	1
Demographic and Clinical Correlates of the Cost of Potentially Preventable Hospital Encounters in a Community Health Center Cohort	1
Health Systems Need to Transform Data Collection to Advance Health Equity	1
Building for Value: A Foundational Structure to Support Population Health	1
Impact of Social Needs in Electronic Health Records and Claims on Health Care Utilization and Costs Risk-Adjustment Models Within Medicaid Population	1
Evaluation of an Interdisciplinary Hypertension Management Program at a Large Primary Care Practice	1
A Call for an American Social Care System: Social Services Reimbursement to Address Fragmented Care	1
Population Health Futures: Would You Invest Your Personal Money?	1
Social Determinants of Health and Pediatric Mental Health Before and During COVID-19 in New York City Primary Care Pediatrics	1
Comprehensive Approach to Opioid Management in a Primary Care Network	1
Evaluating a Care Management Program for Dual-Eligible Beneficiaries: Evidence from Rhode Island	1
A Scoping Review of RCT Studies on Community Health Worker Effectiveness	1