Understanding Population Health

There are numerous ideas, methods, and models when it comes to population health (PH). It is important to recognize that there is no single or widely accepted definition or methodology that exists for PH. The most important thing to recognize about PH is that there are key elements that should be contained within its scope of deployment. Anything you add to these elements is like icing on the cake.

The 10 key elements:

1. Focus on the current health status of the population being addressed
2. Address the determinants of ill-health and their interactions (in the way that health problems may affect certain groups more than others; risk factors that tend to predispose people to poorer health; and, risk conditions that are general circumstances, over which people have little or no control to affect health status)
3. Base decisions on clinical evidence
4. Increase upstream investment
5. Data, data, data, actionable data
6. Provider and patient engagement is mandatory
7. Apply multiple actionable strategies that foster health > healthcare (multiple points of entry to planning and implementation are essential
8. Collaborate across sectors and levels (emerging health issues or issues related to the health of a particular priority group)
9. Employ mechanisms for individual and public involvement in wellness activities
10. Demonstrate provider, patient and plan accountability and responsibility for health outcomes

Of the 10 elements, there are three that rise up to the surface:

1. Information-powered clinical decision-making
2. Primary care provider engagement and leadership
3. Patient engagement and community integration

Models of population health do differ not only in their implicit or explicit definitions but in other key ways as well. 

• They include different categories of factors affecting population health and vary in their relative emphases on certain categories.
• They depict different causal relationships among factors, and between those factors and population health.
• They represent interactions among factors differently.
• They vary in their presentation of factors as actually determining population health rather than influencing it.
• They differ in their distinction between population health and individual health, and the relative influence of various factors on each.

Donald Berwick and colleagues “Triple Aim” concept published by the Institute of Healthcare defines three areas of focus: population health, the experiences of care and per capita cost. This Triple Aim has become the pillars used by CMS, conventional health plans, accountable care organizations, and patient-centered medical homes and meaningful use practice.

According to Berwick, there are preconditions for the Triple Aim that include the enrollment of an identified population, a commitment to universality for its members, and the existence of an organization (an “integrator”) that accepts responsibility for all three aims for that population. He elaborates further by citing that the integrator’s role includes at least five components: a partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration. [Health Affairs 27, no. 3 (2008): 759–769; 10.1377/hlthaff .27.3.759] 

In 2014, in an article by Bodenheimer and Sinsky and published in the Annals of Family Medicine Vol. 12 NO. 6; Nov/Dec that states there should be a fourth aim—improving the work life of healthcare clinicians and staff. This is based on the fact that healthcare providers have a high burnout rate.

According to the article,

"...the wide gap between societal expectations and professional reality has set the stage for 46% of US physicians to experience symptoms of burnout. Widespread across specialties, burnout is especially prevalent among emergency department physicians, general internists, neurologists, and family physicians. In a 2014 survey, 68% of family physicians and 73% of general internists would not choose the same specialty if they could start their careers anew."

This aim clearly does bring up a valid point that directly impacts the other three aims. Thereby, it should be represented as the fourth aim.

PH is no longer just about public health. It has grown; evolved and found several other niches that it can work its magic. There are a few things that need to be cited before moving along the population health pathway. The first thing is health risk prevalence. The second is chronic condition prevalence. The third is the availability of whole person healthcare delivery in a given population.

There is also the factor of prevention; primary [risk reduction]; secondary prevention [screening and treatment]; tertiary prevention [chronic care management]. Each of these follows that patient cycles of group health, primary care, and specialty care respectively.

So how easy is it to improve the health status of an entire population? It is not that easy, but it worth every minute working toward it because it does pay off a hefty dividend. Behavior change is not easy to do because you first have to get the patients to be engaged. Actually, there needs to be the engagement of both the provider and the patient. That dual engagement will foster persistence and from persistence comes retention and retention are the keys to the success of any program.

Then there are the "right ops" that discusses how to operationalize it all. You have the right information right data right intervention right time right method of communication.  One of the mainstays of PH is information sharing. It is critical because it leads to interactivity and meaningful use. Most importantly, the information has to “actionable”, as actionable information yields better decision making on the part of the provider and the patient.

When PH is combined with value-based care it places the provider in the roles of being accountable and responsible for the patients as individuals and as part of the population group. In this venue, each episode of care is not only an encountered transaction but also part of a map of the patient's sojourn on the healthcare continuum. The identification of patients not keeping to appointments, patients not engaged. diagnoses missed for not seeing the patient as a whole during appointments made for other purposes. Addressing patients, not in compliance with treatment regimes. It also looks at continuity and consistency of the provider practices.

The benefits of adapting or adopting the principles of PH are numerous. There is no wrong way to do it when you apply some basic concepts to the process. This is because of each population in a given area, whether that is local, regional, statewide or nationally are uniquely different to that particular geolocation. Thereby, not all things will work or can be applied to other areas. No longer can you characterize rural-to-rural, suburban-to-suburban and urban-to-urban, as it has been the methodology. Understanding what defines a population and recognizing that PH is a central component to all changes in healthcare is the lesson to be learned here today. 

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#populationhealth #pophealth #population health management #tripleaim