Calling the Shots: Nursing News and Notes

Population Health 101

Population Health 101

Tuesday, February 7, 2017

“It’s all about outcomes.” 

This much we know, from the ANCC (American Nurses Credential Center) Magnet model which stresses the various model components and if/how they ultimately move the needle on individual empirical patient outcomes.  So how is population health any different? 

Population health has been defined as improving the health of an entire human population group, as opposed to focusing on individual outcomes. It's an approach to health that holds three common components: health outcomes, patterns of health determinants, and policies and interventions.

An important priority in achieving population health is to reduce health inequities or disparities among different population groups due to, among other factors, the social determinants of health (SDOH). The SDOH include the social, environmental, cultural, and physical factors the different populations are born into, grow up with, and function with throughout their lifetimes. These factors potentially have a measurable impact on the health of human populations.

The population health concept represents a change in focus from the individual-level, characteristic of most mainstream medicine. It also seeks to complement the classic efforts of public health agencies by addressing a broader range of factors shown to impact the health of different populations.

Healthy People 2020

Healthy People 2020 is an initiative and web site sponsored by the US Department of Health and Human Services, representing the cumulative effort of 34 years of interest by the Surgeon General's office and others. It identifies 42 topics considered social determinants of health and approximately 1,200 specific goals considered to improve population health. It provides links to the current research available for selected topics and identifies and supports the need for community involvement considered essential to address these problems realistically.

As providers, payers and policymakers study this health challenge from different angles, it has become clear that population health is a complex, multi-faceted project. Late last year, clinicians, data scientists, technology professionals and other innovators gathered to share best practices for providing high-quality, efficient, accessible care for healthier patient populations.

From quality improvement to patient engagement, and data governance to care coordination, the success of your population health management program depends on the commitment and vision of an array of healthcare professionals: CEOs, CFOs, Chief Data Officers, Chief Patient Experience Officers, Chief Clinical Transformation Officers, physicians, nurses, and even patients.

Technology's Role

Carrying out a population health management program involves risk models for cost reduction, data-enabled resource allocation for accountable care, chronic care management, utilization reduction, EHR optimization, telemedicine, and more.

Each of these come with their own set of challenges – speaking to the enormous task of population health management.

But while population health is a human-centered endeavor, technology can play a huge role.

We know that IT decision-makers want to make the right purchasing decisions as their employers push forward into the new world of accountable care.

Healthcare organizations need to dedicate resources to overcome the technology, staffing, and process challenges that prevent programs from moving forward. While electronic medical records (EMRs) have increased access to patient information, interoperability challenges remain in sharing data across multiple EMR platforms. Using a health information exchange (HIE) with continuity care documents allows all providers access to patient data so that they can make informed decisions to improve care coordination. Emphasizing resource, procedural, clinical, and IT infrastructure investment is essential to creating a clinically integrated network to improve population health.

Population health seems to be a big buzzword in healthcare today. What measures is your facility taking to advance population health management initiatives?

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