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Coursework, Healthcare, Pages: 8

Population Risk Assessment Worksheet (Assignment 1)

Population Risk Assessment Worksheet (Assignment 1)

Population Needs Assessment

To meet the health needs of the Miami-Dade County, Florida, population, you must first assess patients who are underserved in the community and have limited access to care.

Following McKenzie & Pinger’s six-step needs assessment model, complete the following tables to determine the population’s unmet healthcare needs.

Step 1: Determine the purpose and focus of the needs assessment. What questions must you answer about Miami-Dade to identify and address barriers to high-quality, cost-effective, accessible care in the community?: Population Risk Assessment Worksheet (Assignment 1).

To achieve this, several key questions must be answered:

1.    Which population groups in Miami-Dade County experience the highest rates of poor health outcomes and limited access to care?

2.    What percentage of the population is uninsured, underinsured, or relies on emergency Medicaid?

3.    What social determinants, such as poverty, transportation, language, or education, contribute to healthcare disparities?

4.    Which areas of Miami-Dade County lack access to primary, prenatal, or specialty care services?

5.    What is the current cost burden of avoidable hospital admissions, C-sections, and emergency births?

6.    What community resources or healthcare programs can be leveraged to support population health management?

7.    What legislative or reimbursement models are available to support a transition to value-based care?

Step 2: Gather data—research data to complete the chart below.

Population Demographics
Location: Miami-Dade County
Total population: 2,673,837
Factor Category Distribution % # of People Data Source

Gender

 Male 49.2% 1,322,628 (United States Census Bureau, n.d.)
Female 50.8% 1,364,239 (United States Census Bureau, n.d.)

Race

 White 29.4% 790,140 (United States Census Bureau, n.d.)
Hispanic or Latino 70.4% 1,892,216 (United States Census Bureau, n.d.)
Black or African American 13.7% 368,299 (United States Census Bureau, n.d.)
Asian 1.7% 45,677 (United States Census Bureau, n.d.)
American Indian and Alaska Native 0.35% 9,405 (United States Census Bureau, n.d.)
Two or more races 42.8% 1,151,588 (United States Census Bureau, n.d.)
Other 12.1% 325,490 (United States Census Bureau, n.d.)
Total 100% 2,686,867 (United States Census Bureau, n.d.)

Age

 Under 5 5.25% 141,260 (United States Census Bureau, n.d.)
5–18 14.16% 14.16% (United States Census Bureau, n.d.)
19–64 63.1% 1,695,676 (United States Census Bureau, n.d.)
65 and over 17.8% 478,224 (United States Census Bureau, n.d.)
Uninsured individuals 14.3% 384,374 (United States Census Bureau, n.d.)
Persons with a disability under the age of 65 6.0% 161,212 (United States Census Bureau, n.d.)
Persons in poverty 14.9% 399,989 (United States Census Bureau, n.d.)
Median household income $68,694 (United States Census Bureau, n.d.)
Unemployment rate 3.8% 101,921 (United States Census Bureau, n.d.)
Adults with a high school education or higher 83.3% 1,657,049 (United States Census Bureau, n.d.)
Language other than English spoken at home (5 years or older) 75.2% 2,020,500 (United States Census Bureau, n.d.)

 
Urban 99.6% 2,676,830 (United States Census Bureau, n.d.)

 
Rural 0.4% 10,738 (United States Census Bureau, n.d.)

 
Use of public transportation           17.0% 455,767 (United States Census Bureau, n.d.)

Step 3: Analyze data. Describe your findings and data source specific to each of the query questions.

Needs analysis summary
Query Finding Data source
Who is the priority population? The population to be served by the identified priority population, based on Corazon y Alma Health Profile, financial information, and the U.S. Census Bureau information, is the low-income, uninsured, or underinsured women in the reproductive age (15-44 years), especially the ones living in South Dade and Homestead.

These women are brought to an unequal level of healthcare access obstacles, late prenatal lead time, and a big intention of using emergency services as the source of childbirth.

They are more likely to be Hispanic or Black, experience language impediments, and live below the poverty level prescribed by the federal government. This group also produces above-average morbidity and mortality rates of maternal health and babies and excess medical expenditures for complications that are avoidable.

 (United States Census Bureau, n.d.)

 
What are the needs of the priority population? The key healthcare needs of this group include early and continuous prenatal care, access to behavioral health services, transportation support, and language-appropriate health education. Corazon and Alma’s data show high rates of emergency Medicaid births, avoidable C-sections, and neonatal intensive care unit (NICU) admissions.

These outcomes are closely linked to inadequate prenatal monitoring and fragmented care. Additionally, the population lacks routine screening for perinatal depression and gestational conditions such as hypertension and diabetes, resulting in higher rates of maternal readmissions and neonatal complications.

 (Office of the Surgeon General (OSG), 2020)
Which subgroups within the priority population have the greatest need? The most extreme challenges are posed by the larger unreproductive-age population, the undocumented immigrants, foreigners who do not speak English, and those who live in rural or semi-rural areas of the United States like Homestead.

The subgroups tend to have severe delays in receiving care due to their immigration status, fear of public systems, inability to gain insurance eligibility, as well as far travel to the clinics.

The women in these subgroups also live in families with many generations, have little resources, run the risk of being primary caregivers, and might not prioritize medical visits due to the lack of resources.

 (Iceland, 2021)

 
What is the capacity of the community to deal with the needs? Miami-Dade County offers a relatively stable system of healthcare suppliers, community organizations, and agencies of population health. Nevertheless, the capacity of Corazon y Alma is still weak in terms of geographical area of service and culturally customized services.

Although it provides OB/GYN services and social work assistance, the number of those needing such services in the underserved sector exceeds the available number.

The clinic has no satellite facilities in South Dade. Currently, it does not offer integrated behavioral health services or transportation support, which are the two primary needs of the target population.

However, there is an opportunity to expand because bilingual employees, EHRs, and collaborations with local entities are available.

 (Miami-Dade County Community Action and Human Services Department, 2020)
What are the assets in the community on which a program can be built? Assets are the clinical and access of Corazon y Alma to the community, the amount of trust, and Medicaid-managed care networks. The county also has access to the public transit infrastructure, local nonprofits specializing in maternal health are also available, and digital tools may facilitate reaching patients.

The available resources can be used to adopt a value-based PHM approach to maternal and infant care.

 (Miami-Dade County Community Action and Human Services Department, 2020)

Step 4: Identify the factors linked to the health problem. Identify the indication and potential significance in the Miami-Dade community for each barrier-to-care type. Complete the chart below.

Barriers to care
Barrier type Indication in Miami-Dade community Potential significance
Geographic While Miami-Dade is mainly urban, the distribution of healthcare services is uneven. South Dade, Homestead, and rural fringes of the county have limited access to OB/GYN services, prenatal clinics, and hospitals equipped for maternity care. These underserved areas face clinic shortages, long appointment wait times, and limited service hours. Geographic disparities can delay access to prenatal care, a critical factor in preventing pregnancy complications (Holcomb et al., 2021). Women in these areas are more likely to present in emergency departments for labor without prior prenatal visits, which leads to a higher incidence of preterm births, low birth weight infants, and costly NICU admissions.
Financial A significant portion of Miami-Dade’s residents—14.3%—are uninsured, and many low-income or undocumented residents depend on emergency Medicaid. These financial limitations prevent many women from initiating prenatal care early or continuing care throughout their pregnancies. Out-of-pocket costs, even for publicly insured patients, remain a deterrent. Inadequate financial coverage limits preventive care utilization and shifts the burden to emergency services. Emergency Medicaid only covers childbirth-related costs, leading to reactive care strategies rather than preventive interventions (Taylor et al., 2020). This results in high healthcare expenditures for potentially avoidable outcomes such as C-sections and NICU stays, increasing systemic strain.
Transportation While Miami-Dade has a relatively high rate of public transportation usage (17%), availability is inconsistent in outlying areas. Long travel times, complex bus routes, and limited service hours create barriers to accessing care. This is particularly burdensome for low-income women and those with young children. Transportation barriers lead to missed or rescheduled appointments, fragmented care, and reduced treatment adherence. In obstetric care, missed visits can result in undiagnosed gestational diabetes, hypertension, or fetal growth restrictions, which escalate costs and increase maternal mortality risks (Teshale et al., 2025).
Educational Around 17% of the country’s adult population lacks a high school diploma, and over 75% speak a language other than English at home. This creates a significant population with limited health literacy and understanding of the healthcare system. Low education levels hinder patient engagement in prenatal education and informed decision-making. Miscommunication between patients and providers leads to care non-compliance, higher readmission rates, and elevated risks of maternal and neonatal complications. Educational gaps exacerbate mistrust in the system and reduce program effectiveness (Chu et al., 2021).
Socioeconomic With nearly 15% of residents living in poverty and many more experiencing housing instability, food insecurity, or unstable employment, social stressors limit health-seeking behaviors. Many women prioritize basic needs over preventive care. These social conditions contribute to chronic stress, inadequate nutrition during pregnancy, delayed postpartum follow-up, and higher rates of postpartum depression (Saharoy et al., 2023). The economic burden associated with poor maternal health outcomes affects not only healthcare costs but also long-term child development and productivity in the population.

Define the financial implications and market opportunities for the population. After assessing and identifying unmet healthcare needs, complete the following table to define the costs and market opportunities for the population. Review the statistics budget to fill in the table.

Unmet Healthcare Need Market Opportunities Potential Financial Implications
Inadequate prenatal care in underserved areas Expand mobile clinics and satellite OB/GYN services in South Dade and Homestead; offer weekend/evening hours. Reduces costs associated with emergency labor, preterm birth, and NICU use; improves quality scores tied to value-based reimbursement (Hughes et al., 2023)
Delayed or missed enrollment in Medicaid Launch community-based enrollment drives and use bilingual navigators in neighborhoods with low coverage (Mistry et al., 2023) Ensures women receive early prenatal care, allowing for chronic disease management during pregnancy and better outcomes, reducing high-cost interventions
Poor transportation access to clinics Partner with rideshare services (for example, Uber Health), offer clinic-based shuttle services, or fund transit vouchers. Minimizes no-show rates and care discontinuity, increases provider efficiency, and qualifies for PHM-related transportation grants.
Low health literacy and limited access to culturally competent education Develop multilingual digital education campaigns and community health worker programs to improve patient understanding It decreases preventable ER visits, improves medication adherence, and enhances patient satisfaction, all of which support favorable insurance reimbursement (Ferreira et al., 2023).
Lack of integrated perinatal mental health services Embed behavioral health services into prenatal visits and establish referral pathways to tele-mental health providers (Palmer et al., 2022). Prevents long-term maternal mental health crises, improves patient retention, and reduces total cost of care per capita under value-based models

 Step 5: Identify the program focus. Draw a preliminary conclusion. Is a transition to population health management fiscally feasible?

Based on the financial documents provided and the completion of a needs assessment, do you think a transition toward population health management is fiscally feasible for Corazon y Alma? Why or why not? Provide financial data that supports your decision.

Through the presented financial records and the carrying out of a needs analysis, Corazon y Alma is financially viable to move toward population health management. The data on finances point to the inefficiency of the existing care model linked to the high cost of episodic and emergency services, especially regarding maternal and infant health. Corazon y Alma documents high spending on emergency Medicaid births of about 11,000 dollars per birth.

The costs are far more than those incurred during planned and managed prenatal care, about 6,500 dollars per birth (Peterson et al., 2022). By deemphasizing its reactive emergency model in favor of a PHM model, the clinic will be able to decrease the number of avoidable emergencies and minimize the overall expense of maternal care delivery.

Underprivileged individuals who lack insurance or are underinsured also burden the clinic’s financial status. The uninsured rate among the under-65 population of Miami-Dade County constitutes 14.3% (United States Census Bureau, n.d.). Most of the patients use emergency Medicaid, which only covers childbirth but not prenatal and postpartum care.

The outcome of this reactive model is expensive, disorganized care. Early identification and Medicaid enrollment-based PHM strategy would enable Corazon y Alma to receive higher Medicaid reimbursement rates by working with Medicaid managed care organizations (MCOs), thus increasing revenue predictability.

Financial feasibility is also supported by the capability of migrating services within a community-based environment over hospital-based environments. The organization’s infrastructure, including electronic health records for bilingual employees and community health navigators, puts the organization at the end of the possibility of increasing outpatient services and mobile services in underserved cities, such as Homestead and South Dade.

The interventions would minimize the rate of no-shows, promote follow-up adherence, and lower the percentage of costly care that includes C-sections and NICU admission, which are both high at Corazon y Alma.

The clinic also does not have integrated mental services, even though financial analyses show that the higher readmission was associated with untreated perinatal depression. Early intervention and preventive reduction of hospitalizations resulting from a crisis would be possible by including behavioral health screening as a part of the provided OB/GYN services. The integrated clinics have shown savings of 15-20% per patient and maternal health outcome improvement.

Moreover, the Medicaid system in Florida consistently backs value-based care. Through performance metrics, Corazon y Alma would receive maternity episode-based payments, quality improvement, and care coordination bonuses. Such additional payments would supplement revenues and offset the earlier cost of installing the PHM infrastructures.

 Step 6: Validate the prioritized need. Select a target population. Based on your analysis, what population should be targeted for a value-based population health management model?

Based on the needs assessment, demographic data, as well as financial analysis, the population targeted with a value-based population health management (PHM) model at Corazon y Alma should include women of reproductive age (15 to 44 years) in low-income, uninsured, or underinsured families, especially those who live in South Dade and Homestead.

The population experiences several obstacles in care, such as geographic remoteness, economics, low levels of health literacy, and lack of behavioral health facilities (Coombs et al., 202). This has rendered them a group of high priority in terms of being on the receiving end of a preventive and coordinated care model of care that operates under the philosophy of PHM.

The Hispanic and Black women of childbearing age in Miami-Dade County are highly concentrated, especially because some of them live below the federal poverty level. The census statistics reveal that 14.9% of the population lives below the poverty line, with 14.3% of the people under age 65 not holding insurance coverage.

The data provided by Corazon and Alma indicate high rates of emergency births in the Medicaid population and complications related to delayed/missed prenatal care (United States Census Bureau, n.d.). These clinical and financial trends suggest that the target group is not doing well because of poor health outcomes and being a high-cost provider in the current fee-for-service model.

The women in this group tend to either start prenatal care late or fail to start it altogether, which results in conditions that could have been avoided, including preeclampsia, gestational diabetes, preterm birth, and postnatal depression. The conditions lead to the prevalence of emergency C-sections, NICU stays, and maternal readmissions at high levels where the outcome is much more expensive than the outcomes attributed to organized and early prenatal care.

Satisfying the needs of this population with the help of PHM would result in fewer emergency visits and better maternal-infant health outcomes that will lead to decreasing long-term healthcare expenditure.

Also, this group shows a considerable need for numerous social determinants of health. Most of them live in linguistically isolated homes, use mass transit, and do not have access to culturally relevant health education. This would mean introducing a PHM model that could enable Corazon y Alma to work through community health workers, bilingual navigators, mobile clinic facilities, and digital technologies to enhance access and continuity of care.

These strategies have boosted interaction and decreased diversities in comparable populations (Kibuchi et al., 2024). Serving the reproductive population in underserved communities is not only the mission of the Corazon y Alma but also puts the clinic in a good position to achieve value-based care measures linked to Medicaid-managed plans. This group presents the best chance at improved health outcomes, financial sustainability, and lasting impact.

References

Chu, J. N., Sarkar, U., Rivadeneira, N. A., Hiatt, R. A., & Khoong, E. C. (2021). Impact of language preference and health literacy on health information-seeking experiences among a low-income, multilingual cohort. Patient Education and Counseling, 105(5). https://doi.org/10.1016/j.pec.2021.08.028

Coombs, N. C., Meriwether, W. E., Caringi, J., & Newcomer, S. R. (2021). Barriers to healthcare access among U.S. adults with mental health challenges: A population-based study. SSM – Population Health, 15(2), 1–8. https://doi.org/10.1016/j.ssmph.2021.100847

Ferreira, D. C., Vieira, I., Pedro, M. I., Caldas, P., & Varela, M. (2023). Patient satisfaction with healthcare services and the techniques used for its assessment: A systematic literature review and a bibliometric analysis. Healthcare, 11(5), 639. https://doi.org/10.3390/healthcare11050639

Holcomb, D. S., Pengetnze, Y., Steele, A., Karam, A., Spong, C., & Nelson, D. B. (2021). Geographic barriers to prenatal care access and their consequences. American Journal of Obstetrics & Gynecology MFM, 3(5). https://doi.org/10.1016/j.ajogmf.2021.100442

Hughes, C. S., Butrick, E., Namutundu, J., Olwanda, E., Otieno, P., Waiswa, P., Walker, D., & Kahn, J. G. (2023). Cost analysis of an intrapartum quality improvement package for improving preterm survival and reinforcing best practices in Kenya and Uganda. PLoS ONE, 18(6), e0287309. https://doi.org/10.1371/journal.pone.0287309

Iceland, J. (2021). Hardship among immigrants and the native-born in the United States. Demography, 58(2). https://doi.org/10.1215/00703370-8958347

Kibuchi, E., Chumo, I., Kabaria, C., Elsey, H., Phillips-Howard, P., De Siqueira-Filha, N. T., Whittaker, L., Leyland, A. H., Mberu, B., & Gray, L. (2024). Health inequalities at the intersection of multiple social determinants among under five children residing Nairobi urban slums: An application of multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). PLOS Global Public Health, 4(2), e0002931. https://doi.org/10.1371/journal.pgph.0002931

Miami-Dade County Community Action and Human Services Department. (2020). Comprehensive Community Needs Assessment. https://metropolitan.fiu.edu/research/periodic-publications/recent-reports/comp-community-needs.pdf

Mistry, S. K., Harris, E., Li, X., & Harris, M. F. (2023). Feasibility and acceptability of involving bilingual community navigators to improve access to health and social care services in general practice setting of Australia. BMC Health Services Research, 23(1). https://doi.org/10.1186/s12913-023-09514-4

Office of the Surgeon General (OSG). (2020). Strategies and actions: Improving maternal health and reducing maternal mortality and morbidity. The Surgeon General’s Call to Action to Improve Maternal Health – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK568218/

Palmer, C. S., Levey, S. M., Kostiuk, M., Zisner, A. R., Tolle, L. W., Richey, R. M., & Callan, S. (2022). Virtual care for behavioral health conditions. Primary Care: Clinics in Office Practice, 49(4), 641–657. https://doi.org/10.1016/j.pop.2022.04.008

Peterson, J. A., Albright, B. B., Moss, H. A., & Bianco, A. (2022). Catastrophic health expenditures with pregnancy and delivery in the United States. Obstetrics & Gynecology, 139(4), 509–520. https://doi.org/10.1097/aog.0000000000004704

Saharoy, R., Potdukhe, A., Wanjari, M., & Taksande, A. B. (2023). Postpartum depression and maternal care: Exploring the complex effects on mothers and infants. Cureus, 15(7). https://doi.org/10.7759/cureus.41381

Taylor, Y. J., Liu, T.-L., & Howell, E. A. (2020). Insurance differences in preventive care use and adverse birth outcomes among pregnant women in a Medicaid nonexpansion state: A retrospective cohort study. Journal of Women’s Health, 29(1), 29–37. https://doi.org/10.1089/jwh.2019.7658

Teshale, M. Y., Bante, A., Belete, A. G., Crutzen, R., Spigt, M., & Stutterheim, S. E. (2025). Barriers and facilitators to maternal healthcare in East Africa: A systematic review and qualitative synthesis of perspectives from women, their families, healthcare providers, and key stakeholders. BMC Pregnancy and Childbirth, 25(1). https://doi.org/10.1186/s12884-025-07225-8

United States Census Bureau. (n.d.). QuickFacts: Miami-Dade County, Florida. Census Bureau QuickFacts. https://www.census.gov/quickfacts/fact/table/miamidadecountyflorida/BZA110216#viewtop

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Question 

Assignment 1: Financial Benefits of Population Health Management (PHM)
Conduct a needs assessment to determine the target population that would benefit from a transition to a value-based population health management model.

The Population Risk Assessment worksheet (Assignment 1) is based on McKenzie and Pinger’s six-step model. For this assignment, you will complete an adapted version of a needs assessment to identify a target population.

For Assignment 1, do the following:

  • Review the Corazon y Alma Health Profile and Corazon y Alma Health Financial Data documents. Additional information may be found by researching the U.S. Census Bureau QuickFacts for Miami-Dade County, Florida.
  • Complete the Population Risk Assessment worksheet (Assignment 1) to accomplish the following steps:
    • Interpret data to determine the unmet healthcare needs of the target population.
    • Define health costs for the target population.
    • Research policies, legislation, and regulations relevant to transitioning PHM to a value-based care model.

Additional Resources

References