MMHA 6540 Week 1 Population Scoping Memo Example

Memorandum

To: Director of Population Health, Prairie Gate Health Plan

From: Population Health Analyst (MMHA student)

Date: Month Day, Year

Re: Scope for this year's population health initiative: members 65 and older in our three counties

Working Definition

For this initiative, population health management means five steps: define a group, identify its members from data the plan holds, sort them by need, offer each subgroup a program matched to that need, and measure results over time. The definition is deliberately practical. Population health, in the broad sense Kindig and Stoddart (2003) describe, concerns the outcomes of a whole group and how those outcomes are distributed within it. A health plan can influence only part of that picture, through its members and the services it pays for, so its population health work must start with a group it can identify and reach.

Scope

This memo proposes that the initiative focus on Prairie Gate's members aged 65 and older, most enrolled through the plan's Medicare Advantage product, in the three counties the plan serves. Table 1 shows the scope in round, illustrative figures.

Table 1

Residents and Plan Members Aged 65 and Older by County (Illustrative)

Resident counts are rounded from census estimates; member counts from the plan's enrollment file.

What the Scope Shows

Most members live in Lindon County, the metro county, but the two rural counties hold an older and more isolated share of the plan's members. In Ash and Corley, a larger proportion of members are over 80, more live alone, and clinics and hospitals are farther away. A program designed only around the metro county's services would miss the members likely to face the greatest barriers. The plan covers about one in five older residents in the three counties, so whatever it does will reach only part of the older population; partners serving all residents, such as the area agency on aging, will matter for both reach and design.

Why the Triple Aim Frames the Choice

The Triple Aim holds that health systems should chase three aims together rather than one at a time: healthier populations, better care as patients experience it, and lower cost per person (Berwick et al., 2008). Its strength is that it keeps cost from becoming the only goal or being ignored. For scoping, the third aim is the most useful constraint. Prairie Gate is paid a fixed amount per member each month, so per capita cost is not abstract: a program that improves health but raises costs per member beyond what the plan can sustain will not last. The initiative should therefore look for a need where better health and lower avoidable cost point in the same direction, such as a condition that causes expensive emergency visits and admissions that a program could prevent.

What Is In and Out of Scope

In scope: plan members aged 65 and older living in the three counties, including members in assisted living. Out of scope for this initiative: members living long term in nursing homes, whose care is organized differently and who are better served by the facilities' own programs; members under 65, including younger members with disabilities, who deserve their own initiative; and residents who are not plan members, though partners may serve them. These boundaries can be revisited after the first year.

Next Steps

If you agree with this scope, the next steps are to identify candidate needs for this population, profile the burden of the leading candidates using public and plan data, rank them against criteria agreed in advance, and assess which community partners are ready to help. I propose to bring a ranking to you within six weeks. Falls among older adults are a likely candidate, given their frequency and cost, but the ranking should be done before the plan commits to any single need. Medical spending on falls among older adults is substantial nationally (Florence et al., 2018), and much of it comes from emergency visits and admissions that a plan pays for directly, which is why falls fit the Triple Aim test described above.

Three other candidates should be profiled alongside falls so that the ranking is a real comparison: social isolation, which is common among older adults living alone and has measurable health effects (National Academies of Sciences, Engineering, and Medicine, 2020); medication burden, since many older members take numerous prescriptions with risks of interactions and falls; and food insecurity, which the plan's care managers report in a growing share of assessments. Each candidate will be profiled with the same sources, so that differences reflect the needs rather than the data available.

Data and Partners the Initiative Will Need

Scoping already shows what the initiative will need. On the data side, the plan's claims and enrollment files identify members and their emergency visits and admissions; county emergency medical services agencies hold records of calls that never reach a hospital; and public sources such as state hospital discharge data and federal injury statistics describe the wider community. On the partner side, the area agency on aging serves all older residents and runs community programs; home repair and transportation nonprofits operate in the metro county and, more thinly, in the rural counties; and network primary care practices see most members at least once a year. The initiative's design will depend on which of these partners are ready to work with the plan, which is why a readiness assessment is part of the work plan.

References

Berwick, D. M., Nolan, T. W., & Whittington, J. (2008). The triple aim: Care, health, and cost. Health Affairs, 27(3), 759-769. https://doi.org/10.1377/hlthaff.27.3.759

Florence, C. S., Bergen, G., Atherly, A., Burns, E., Stevens, J., & Drake, C. (2018). Medical costs of fatal and nonfatal falls in older adults. Journal of the American Geriatrics Society, 66(4), 693-698. https://doi.org/10.1111/jgs.15304

Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380-383. https://doi.org/10.2105/AJPH.93.3.380

National Academies of Sciences, Engineering, and Medicine. (2020). Social isolation and loneliness in older adults: Opportunities for the health care system. The National Academies Press. https://doi.org/10.17226/25663