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Population Health Assessment and Strategy

The HPR methodology emphasizes a population health approach while utilizing individual and household-level data to provide a unique model for understanding and influencing targeted populations. The HPR model delivers a comprehensive population health assessment with the individual-level consumer data necessary to support a deeper understanding of the sub-populations of Client interest. In an outcomes-based environment, it is essential to manage patient populations effectively in terms of access, quality and cost of service. Understanding and influencing the behavior of individual patients, plan members and employees facilitates thoughtful groupings for engagement, communication and intervention initiatives. HPR and its partners are able to provide Clients with access to critical life circumstances and social determinants indicators for most households and consumers within the United States.


Life and Social Circumstances Intelligence

The demographic, psychographic, communication and personal interest metrics that HPR provides at the household and consumer level extend the information included in most patient records and standard demographic reports. HPR Advisors are able to develop complete profiles of patients, consumers and households of interest to Clients with these data. Health and wellness initiatives are often undertaken with limited information that addresses the life circumstances and social determinants for individual program participants. These important metrics can be challenging.

The LCI model has been developed at HPR to include:

  • Life circumstances metrics for individuals and their households – race, ethnicity, educational attainment, poverty status, psychographics classification
  • Social determinants of health metrics for individuals and their households -- family structure, household income, housing stability, capacity for change, interest in health/nutrition, interest in reading
  • Neighborhood-level social determinants of health metrics in specified geographic areas – access to nutritious food, proximity of criminal activity, access to public transportation, proximity of toxic waste, housing issues
  • Analytical models that integrate data on disease prevalence, healthcare utilization and healthcare cost at the patient, plan member or employee level
  • Engagement potential metrics that facilitate identifying and intervening with higher-risk patients, plan members and population groups
  • Segmentation models that guide the development of intervention and communication strategy


The LCI model provides a sound foundation for engagement segmentation and evaluation of population health strategy options utilizing accessible demographic, psychographic, and socioeconomic attributes. In addition, the LCI model can be useful to Clients in efforts to anticipate chronic health events and the select appropriate interventions. Minimizing healthcare costs for at-risk populations and sub-population members is usually an important challenge.  


Neighborhood SDOH Risk Assessment

Neighborhood-based social determinants of health (SDoH) flags can be transformed into individual risk profiles for patients, health plan members,and employees with the LCI model in combination with geo-spatial analysis. Additional neighborhood-based SDoH risk factors can be included in the HPR model as the need arises (e.g., Healthy People 2020 specifications). These metrics require additional analysis that typically depends on access to relevant data for geographic areas or neighborhoods of interest. Neighborhood-based SDoH metrics are particularly useful in addressing the needs of disadvantaged populations.  


Engagement Segmentation and Strategy

HPR has developed a model that assigns identifiable U.S. households to five Context Groups which reflect their psychosocial status. The LCI model also addresses consumer assessments that can be both complicated and challenging by segmenting populations into nine Engagement Segments. LCI metrics guide the assignment of households to one of nine distinct Engagement Segments. These groupings combine low, moderate or high capacity to support health related challenges with a low, moderate or high interest in health and nutrition, across all 5 of the HPR Context Groups. The resulting Engagement Segments, thereby, range from high capacity in combination with high interest in health and nutrition individuals to low capacity in combination with low interest in health and nutrition individuals.  


Life Circumstance Flags

The Life Circumstances Flag model implemented by HPR also anticipates life and social conditions that are often associated with recurring healthcare problems, higher service utilization patterns and significant healthcare cost. While consumer populations frequently display disproportionate concentrations healthcare events and cost among a limited number of at-risk individuals, HPR Engagement Segments with moderate and low capacity to support health challenges and moderate and low interest in health and nutrition report a disproportionate number of flags for life circumstances and social challenges. These include:


  • Live Alone
  • Live Alone and Aging
  • Limited Income
  • Housing Instability
  • Minority Status
  • Single Female with Children


Patients with limited income, housing instabilities, minority status and who live alone are often classified by the LCI engagement segmentation model in the higher-risk engagement segments. Download the MAP Case Study on the Resources page.  


Communication and Messaging

With the support of HPR data partners, the communication metrics included in the LCI model are able to describe broadcast media and digital communication preferences as well as messaging strategies most likely to resonate with the households of targeted individuals. The LCI model Version 3.0 provides these data at both the individual and household levels. The appeal of cable, streaming and traditional television, digital and traditional newspapers, direct mail, radio, digital display and video, mobile video and E-mail messaging are all included. The impact of social media in general can be evaluated at a household level as can the individual impact of the principal social media options. The fit of alternative messaging approaches can be evaluated for multiple messaging models. HPR Advisors and Clients are able to assess preferred communication channels in combination with the most effective messaging strategies for both individuals and defined population groups utilizing LCI model Version 3.0.  


Prospective Health Risk Assessment for Defined Populations

The Prospective Risk Assessment (PRA) model developed by HPR enables Advisors to systematically estimate the prospective disease prevalence by disease category for any defined population in the United States. Disease patterns, medication use, and emergency department diagnoses as well as inpatient diagnoses for defined populations, or population groups, can be estimated at specified levels of granularity. Authoritative estimates of physician office visits by medial specialty, hospital admissions, hospital days and the average length of stay are additional outputs of the PRA model for demand analyses that are supported by HPR. The PRA model incorporates national survey data developed by the National Center for Health Statistics as well as other patient and consumer data.  


Health Services Demand Modeling

The experience of HPR Advisors provides Clients with the professional resources needed to develop comprehensive and in-depth profiles of market and facility service areas. These assessments are important components of most Community Health Needs Assessments (CHNA). While many markets are defined in terms of geography, there are cases when a targeted demographic group or psychographic cluster becomes of primary interest to the Client. HPR is able to segment target markets and profile consumer groups in terms of their demographic, socioeconomic and psychographic attributes. HPR can support Client initiatives to estimate the prevailing need for targeted health services in a reliable manner. Other relevant factors such as existing services, the level of insurance coverage and barriers to access also can be evaluated. The HPR model is leveraged with access to household-level data that allow in-depth understandings of healthcare consumers and their profiles. Authoritative estimates of the prevailing demand for targeted health services are routine projects at HPR.  


LCI Partner Relationships

HPR Partners may elect to integrate selected Analytic Resources into their deliverables. Access to individual and group level LCI metrics, engagement risk indicators as well as communication and messaging preferences can add value to the products and services of HPR Partners. LCI metrics are provided for identifiable patients, plan members and other individuals based on their street address. HPR data models observe HIPAA privacy guidelines to provide both the Core LCI Metrics and Complete LCI Metrics deliverables. These metrics are more fully described in the LCI Metric s and Metric Groups document that is available upon request. LCI metrics for individual patient and plan members are delivered by HPR in specified formats. Records are de-identified with a unique personal identifier. An additional feature of the LCI model is the opportunity to provide individual and household-level data for targeted populations (e.g., geographically defined areas).