Population health is “an approach [that] focuses on interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations.” Bridging the gap between population health and healthcare delivery is becoming more important for efficiency, improved quality, and cost-reduction. A population health approach can be used to improve outcomes and reduce costs by:
- Segmenting Patient Populations;
- Identifying Risk Factors;
- Utilizing Primary Medical Care Home Delivery Models;
- Using Evidence-Based Screening and Prevention in Assigned Populations;
- Focusing on Overall Health; and
- Moving from Volume-Based to Value-Based Care.
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A population health approach is a useful strategy to aid health organizations in improving patient outcomes for specific groups (e.g., those with chronic conditions such as chronic obstructive pulmonary disease and/or population sub-groups such as women of childbearing age). These kind of approaches also have the potential to save resources by reducing health care utlization (e.g., hospitalization and emergency department visits through prevention efforts). In particular, the strategies detailed in this article have demonstrated impact in a number of settings ranging from primary care to acute care hospitals, to public health clinics.
Segmenting Patient Populations
Possible methods for grouping populations to improve care include age, gender, disease or condition, social and demographic factors, behaviour, and risk stratification on one or more of these variables. The most commonly used methods are by age and disease or condition; with risk stratification. Risk stratification can display a more precise view of the population under consideration.
Segmenting patient populations using risk stratification is a critical first step in developing an appropriate population health strategy. Common risk groups include low-risk, rising-risk, and high-risk groups. The division of the population into groups of apparent risk is the first step to addressing the high cost of chronic diseases. This creates the possibility to decrease preventable readmissions, and connect sub-populations to community-based resources to enable individuals to live healthier lives.
Though high-risk patients are also high-cost patients who have more than one chronic disease, the rising-risk population accounts for a higher amount of healthcare expenditures due to the high percentage of the population that they account for. The rising risk group is not ill enough for expensive clinical care, but they are also past the point where preventive solutions are effective. This gap is important to address in order to prevent the increasing multi-morbidity in the population.
- White Paper: Chronic Disease is Healthcare's Rising Risk
- Case Study: St. Joseph's Healthcare's Integrated Comprehensive Care Project
Identifying Risk Factors
There is a small number of causes or risk factors, that contribute to most chronic disease. These include an unhealthy diet, physical inactivity, and tobacco use. These are the first-degree risk factors that are modifiable. These risk factors contribute to an intermediate set of risk factors such as hypertension, raised glucose levels, abnormal blood lipids, and obesity. These modifiable risk factors combine with non-modifable risk factors such as age and heredity; to establish most of the chronic diseases around the world. Therefore, the prevention and screening of risk factors enables a reduction in chronic disease.12
Utilizing Primary Medical Care Home Delivery Models
Primary care medical homes are models of primary care that are patient-centered, comprehensive, team-based, coordinated, accessible, and are focused on both safety and quality.9 They are comprised of various providers in different disciplines to provide comprehensive and personalized care in an inter-professional team. The foundation of the medical home is the relationship between the patient and their primary physician. The medical home contributes to a population health approach that promotes wellness and helps patients prevent illness.
- White Paper: Coordinating Care in the Medical Neighborhood: Critical Components and Available Mechanisms
- Case Study: Improving Population Health at Children's Hospital Boston for Asthma Patients
- Case Study: Patient-Centered Primary Care Collaborative a Key Solution for Healthcare Fragmentation: Medical Home Network
Using Evidence-Based Screening and Prevention
Focusing only on sick patients and patients with existing risk factors will be ineffective in controlling healthcare costs in the long run. As the largest driver of escalating healthcare costs is the expensive treatment of chronic disease, more preventive healthcare is necessary. The prevention of illness in the groups of patients who may become ill is important to reduce rising healthcare costs. There are sources for evidence-based preventive recommendations that can be accessed by healthcare providers around the world and applied to healthy and low-risk populations throughout the lifespan.
Focusing on Overall Health
Evidence suggests that people living in disadvantaged circumstances tend to be less healthy than their more advantaged counterparts. Additionally, people who grow up in poverty and substandard housing have higher mortality and morbidity rates and increased healthcare costs. These determinants of health are also important drivers of health services utilization patterns over time. For the health system to improve the health of the population, while containing costs; more resources must be spent on health promotion and disease prevention. The increased emphasis on the population health approach, which decreased attention of purely the treatment of patient-centered illness is important. Better health outcomes can be achieved through the health system spending money on building healthier communities, with social supports and nourishing environments. Health policies need to expand to address factors outside the medical system that promote or compromise health.
- The Case for Investing in Public Health
- Changing the Patient Behaviour: The Next Frontier in Health Care Value
- Economic Arguments for Shifting Health Dollars Upstream
Moving from Volume-Based to Value-Based Care
Current health systems in both Canada and the United States tend to emphasize volume (i.e., utilization) in healthcare over value. These funding systems historically have not provided incentives or encouraged providers to consider the cost of care and how it affects the overall health system. By moving the economic model from that of a "sick system" to one focused on prevention, encouraging patient engagement, and reducing expenditures will reduce costs and improve care. The shift to a system of value-based care are occurring but will take time, with some growing pains along the way. In the interim, there are various ways healthcare systems can implement some of the elements of value-based care. For example, by improving communication around hand-offs, calling patients after discharge to identify issues of concern and removing waste (non-value-added activities) within the system, patient care across the care continuum will be improved.
- Article: What is Value-Stream Mapping?
- Article: How Can Unnecessary Health Care Utilization be Eliminated?
- Tool: 5 Initial Steps to Move From Volume-Based to Value-Based Healthcare
Population health management is an effective strategy to control increases in healthcare spending and the incidence of chronic disease, while improving outcomes for specific patient populations. Focusing on the prevention of illness before the clinical stage is key to this endeavour. The segmentation of populations and the identification of risk factors helps to address the underlying causes of chronic diseases, and the implementation of these approaches directs care and prevention to those most in need. Using new forms of more broadly linked treatment options such as value-based care and primary care medical homes allows patients to be treated seamlessly and with better integration between providers. Need more information? Have some resources to share? Please visit the Population & Public Health Community of Practice and ask a question in the discussion space and/or upload files to share with your colleagues.
- Population Health: An Implementation Guide to Improve Outcomes and Lower Costs
- What Determines Health?
- The Case for Investing in Public Health
- Economic arguments for shifting health dollars upstream
- 5 Initial Steps to Move From Volume-Based to Value-Based Healthcare
- Moving toward Value-based Payment Models in Canadian Healthcare
- Making the Case for Investing in Public Health and the SDH
- Chronic Disease is Healthcare's Rising Risk
- Defining the Medical Home
- Patient-Centred Primary Care in Canada: Bring It On Home
- Population Health Management: Real-Time State-of-Health Analysis
- Chronic diseases and their common risk factors