Published November 10, 2015

What Is Population Health, Anyway? – Part I: From a Theoretical to an Operational Definition

A Five-Part Series
Part I:  From a Theoretical to an Operational Definition

Last year, everyone in healthcare was talking about clinical integration. This year’s buzzword is population health. In our previously published Glossary of Terms for Payment and Delivery System Reform we offered a simplistic definition of this term:

This academic discipline, developed in Canada, studies why people who live in different locations experience different degrees of health and wellness.  Research in this field focuses on social determinants of health:  education, wealth, geographic location, and class.  Many who study population health believe your zip code is more important than your genetic code in predicting health outcomes.

We now realize that describing population health as an academic discipline misses the mark.  Instead, to provide any real meaning, we must move from a theoretical to an operational definition of population health.

To this end, population health needs to be put into the context of how to manage it, i.e., what must occur operationally to achieve improved health status of the defined population.

Population health management is generally regarded as a four-step process:

  1. Identifying those high-risk and rising-risk individuals in the defined population; i.e., risk stratifying the population.
  2. Defining and implementing clinical practice guidelines and care management programs among the provider team.
  3. Engaging identified individuals using these guidelines and services.
  4. Ensuring healthy individuals receive regular preventive services and wellness resources.

This implies population health has three operational aspects that must be addressed: a clinical aspect, an organizational aspect, and a technical aspect.  Over the next two weeks, we will examine each of these aspects in a separate blog entry.  The final entry in this five-part series will be our 10-step plan of attack for population health.

In our nation’s historical fee-for-service-based healthcare economy, providers interact with patients only when they present to the physician’s office or to the hospital or its emergency room; i.e., sick care.  To impact population health, providers must proactively interact with patients to promote healthy lifestyles; i.e., wellness care.

In pursuit of population health, our healthcare system must shift from an event focus to a process focus.  It must address the health of the whole person and all of the social, environmental, and hereditary factors that impact health.  Providers must learn and deploy methods of treatment that achieve efficiency and improve the overall health status of the population for which they are responsible.  In addition, the individuals comprising the population itself must be engaged in the process and take responsibility for their health and well-being more directly and personally, while guided by the providers.

We now have set our sights on the Triple Aim: the simultaneous pursuit of improving the experience of care, improving the health of populations, and reducing per capita costs.  When he first spoke of this new direction for healthcare, Dr. Don Berwick with the Institute for Healthcare Improvement (and later acting CMS Administrator) identified a corresponding three-part foundation from which to reach for the Triple Aim:   (1) the enrollment of an identified population, (2) a commitment to universality for its members, and (3) the existence of an organization – an “integrator” – that accepts responsibility for that identified population.  As envisioned by Dr. Berwick, the integrator’s role would include partnership with individuals and families, redesign of primary care, population health management, financial management, and macro system integration.[1]

As today’s healthcare organizations strive to become integrators, they must appreciate how all aspects of their current operations – clinical, organizational, and technical – must change to meet the demands of population health.   Through this transition, these organizations will move from healthcare providers to population health champions.

[1]   Berwick, Donald M., Thomas W. Nolan, and John Whittington. The Triple Aim: Care, Health and Cost, HEALTH AFFAIRS 27, no. 3 (2008): 759-769.


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