BCACP Population-Based Care 3 — Questions and Answers
Question 1: Which risk stratification tool is commonly used to identify high-risk patients most likely to benefit from intensive ambulatory care management?
- CAGE questionnaire
- Hierarchical Condition Categories (HCC) scoring (Correct answer)
- CURB-65 score
- Wells criteria
Correct answer: Hierarchical Condition Categories (HCC) scoring
HCC scores are used in value-based care models to stratify patient risk and predict resource utilization, guiding population health interventions.
Question 2: A pharmacist wants to address medication adherence gaps across an entire patient panel. The MOST scalable first step is to:
- Call each non-adherent patient individually
- Analyze pharmacy dispensing data to identify patients with PDC <0.80 (Correct answer)
- Wait for patients to report missed doses at clinic visits
- Review all discharge summaries from the past year
Correct answer: Analyze pharmacy dispensing data to identify patients with PDC <0.80
Proportion of Days Covered (PDC) analysis of dispensing data allows efficient, data-driven identification of non-adherent patients across a large panel.
Question 3: In a patient-centered medical home (PCMH), the pharmacist's role in population-based care most commonly includes:
- Serving as the primary prescriber for all chronic conditions
- Conducting panel reviews, identifying care gaps, and providing medication management (Correct answer)
- Managing inpatient medication reconciliation only
- Dispensing medications and counseling at point of sale
Correct answer: Conducting panel reviews, identifying care gaps, and providing medication management
In PCMHs, pharmacists collaborate as part of the care team to review patient panels, close care gaps, and optimize medication therapy.
Question 4: A health system wants to reduce preventable emergency department visits for patients with asthma. Which population health intervention is most directly aligned with this goal?
- Expanding inpatient pulmonology services
- Implementing an asthma action plan program with telephonic follow-up (Correct answer)
- Adding albuterol to the formulary preferred tier
- Increasing the number of pulmonologist referrals
Correct answer: Implementing an asthma action plan program with telephonic follow-up
Proactive asthma action plans combined with telephonic follow-up address medication use and triggers in the ambulatory setting, reducing acute exacerbations.
Question 5: The concept of 'population health management' differs from traditional disease management primarily because it:
- Focuses exclusively on patients who have presented to a provider in the past year
- Addresses the health of an entire defined population, including those not actively seeking care (Correct answer)
- Is limited to chronic disease patients enrolled in Medicare
- Relies solely on patient self-reporting for data collection
Correct answer: Addresses the health of an entire defined population, including those not actively seeking care
Population health management encompasses all individuals within a defined group—including those not currently engaged with the health system—unlike disease management which targets active patients.
Question 6: Which of the following is the best example of a structural quality measure in a population-based pharmacy program?
- Percentage of patients who achieved blood pressure control
- Number of patients who received pharmacist counseling
- Availability of a certified pharmacist-led diabetes education program (Correct answer)
- Rate of 30-day hospital readmission
Correct answer: Availability of a certified pharmacist-led diabetes education program
Structural measures assess the capacity and systems in place (e.g., program availability, credentials), not processes or outcomes.
Question 7: When evaluating a population-based intervention, a 'balancing measure' is used to:
- Confirm that the primary outcome improved
- Detect unintended negative consequences of the intervention (Correct answer)
- Compare costs before and after implementation
- Assess patient satisfaction with the intervention
Correct answer: Detect unintended negative consequences of the intervention
Balancing measures monitor for unintended harms or trade-offs caused by an improvement effort, ensuring the intervention doesn't cause problems elsewhere.
BCACP Population-Based Care 3
Which risk stratification tool is commonly used to identify high-risk patients most likely to benefit from intensive ambulatory care management?