Models of Population

Health
Envisioning an Expanded Model of a Population Health
 Agenda
• Reviews
• Population Health Framework
• Expanded Model of Population Health: Community Health Business
Model
• New Population Health Management
 Review
• Organizations must broaden their focus to organize care to meet the
needs of a defined population
• CareOregon, Genesys, QuadMed
• It requires strong partnership: (health plan/ health system/ purchasers) &
(care providers or community organizations)
 Population Health Framework
Health outcomes Patterns of health
and distribution in determinants over
a population the life course

Policies and
interventions at
the individual and
social levels

Source: Kindig & Stoddart, 2003

 Determinant of Health Model

Source: Adapted from Evans &

Stoddart model, Kindig & Stoddart
(2003)
 National and State Health Goals
• The ultimate purpose of population health policy and interventions is to
improve the health of individuals and populations by investments in the
determinants of health.
• Without careful attention to the outcomes, attention to determinants and
policies could proceed without reference to the ultimate goals and become
ends instead of means to an end.
 National and State Health Goals
• Because improving population health requiring actions on multiple
determinants, no single entity can be held accountable for achieving the
goals.
• Collaborative efforts are needed across sectors and actors.
 Current Health Outcomes
• As a nation, in terms of our health outcomes, we lag most developed countries
by a wide margin, despite spending substantially more (IOM 2013).
• In addition, significant geographic variation is seen in health outcomes within
the United States (County Health Rankings), including unacceptable
disparities in morbidity, mortality, and risk factors.
• Absolute worsening of mortality rates in many US counties has been noted
over the last several years (Kulkarni et al. 2011; Kindig and Cheng 2013).
 Community Health Business Model
• Essential contributions must also come from those that have secondary
influence on health outcomes, such as business, education, state and
local government, community development, and philanthropy.
• "solution lies in the principle of shared value, which involves creating
economic value in a way that also creates value for society by addressing
its needs and challenges" (Porter and Kramer 2011).
 Community Health Business Model
• All stakeholders must be engaged
• Transparent
• Leadership
• Common Purpose
• Resources
• Collective and in-kind evidence-based interventions
• Economic incentives
• Must be assessed and monitored continually with feedback loop
Population Health Framework
Source: Care Continuum Alliance. Outcomes Guidelines Report, vol. 5. Washington, DC,
2010.
 Community Health Business Model
• Require the commitment, supportive policies, and infrastructures of state,
regional, and federal levels of government to assign the appropriate
national context to the importance of health improvement,
• Provide incentives for that improvement in communities,
• Provide information against which a community may evaluate its success
relative to other communities.
• County Health Ranking (MATCH) Model
 Triple Aim
• The Triple Aim proposes that improvement initiatives pursue a broad
system of linked goals: the improvement of individual experience of care,
the improvement of the health of populations, and the reduction of per
capita cost of care for populations.
• Three aims of the National Quality Strategy are better care, healthy people
and communities, and affordable care.
 Reaching Beyond Core Mission
• HealthPartners created a set of materials and tools to promote healthy eating for
schools, workplaces, and individual consumers.
• It was determined that these existing assets could be deployed more broadly in
partnership with community-based organizations and schools.
• State and public health data were also reviewed, and HealthPartners staff participated
in many local and state planning activities, obtaining a sound knowledge of
community health priorities.
• Areas were prioritized for consideration by matching the best assets of HealthPartners
with the highest need.
Reaching Beyond Core Mission
 Beyond Health Care to Community
• Leadership may come from the healthcare sector, and in others, it may
come from public health entities, businesses, or community organizations.
• It will eventually evolve to include sectors such as agriculture and
transportation, where the health impact is less direct
 Incentives
• Moral: Corporate Social Responsibility
• Regulatory: Laws
• Financial: Value-based Reimbursement
 Resources
• Reduce Waste – CMS Innovation, community benefit resources required
by the Internal Revenue Service for nonprofit hospital tax-exempt status.
• Better ROI from Other Programs
• Government Funding for PH
• Philanthropy
• Engage Corporate Business Leader
 Resource Allocation
• Better evidence is needed to inform cost effective investment.
• Bradley and colleagues (2011) argue that an important reason for the poor
performance of the US health system is the relative proportion of non
healthcare social services spending to health services spending: in other
developed countries it is 2.00 to 1, whereas in the United States it is 0.91
to 1.
 Next Steps
A community business model that involves all sectors in partnership can
function as a road map
• Public- and private-sector policymakers should stimulate conversations and
efforts to better understand the specific opportunities for improvement
within each segment of society.
• Policy maker should make the business case for population health
improvement and the resources and policies each type of community actor
requires through its national networks and directly to leaders in each sector
 Next Steps
• Foundations and government should collaborate to develop a catalogue of
cost-effective health-in all policies in sectors beyond health, which could
be reinforced by financial or regulatory incentives.
• Seek out and disseminate effective examples of work currently being done
in communities.
• Benchmarks of the minimal and optimal cross-sectoral investments should
be developed and promoted.
The New Population Health Management
• ACO’s PHM 5 traditional categories of activities: demand management,
lifestyle management, disease management, catastrophic care
management, and disability management.
• Three new categories of activities: panel management, patient-centered
care, and community outreach (schools, health department, social service
agencies)
 Target of the PHM: Patient Populations
• Traditional vs. New approach
• Traditional: individuals seeking healthcare services from the ACOs
• New: patient panel (all patients enrolled in the ACOs) and community-
linked
 PHM Activities
• Panel Management: gaps in care analysis, wellness registries
• Patient-centered Care: patient portal, communication (newsletter, social
media), incorporate patient feedback
• Community Outreach: partnership with school and faith-based
organizations, or a large multi-stakeholder group.
 Case Study 1
• Explain how the company put their mission, vision and value into actions. Who
is their target population of interest?
• What are some of the main results or the actions? How do they measure
success of their actions?
• Are there any potential unexpected/unusual results? What could be the reasons?
• How to ensure continuous success without spending too much money, while
not compromising on quality?