You may have read about “population health” as a way to manage wellness and disease. What is population health? It is caring for whole populations (groups of people) to improve the health and well-being of everyone, regardless of where they are getting care (hospitals, clinics, home) or of who pays. Population health addresses health patterns of a specific group of people to prevent illness, promote wellness and care for people when they are sick.

Who makes up a population?

Everyone is part of a population. Groups are made up of individuals, and every individual counts. A population may be defined by geography, health condition, payer (who pays for their health care such as an insurance company or a government program such as Medicare), literacy or other social factors that tie a group of people together.

While health care teams continue to care for individual patients, population health tracks and measures group outcomes. This approach helps us know if we are making a difference in the health outcomes of different groups.

How does population health help patients?

To improve health outcomes, health care providers need to know their patients and populations. We can then address specific population needs, including those based on geography, health condition, payer, literacy, income, education, housing and other factors that determine health. By addressing the risk factors of illness, people can take preventive steps to stay well and have a higher quality of life.

Good population health management helps avoid episodic, fragmented care. Staying in touch with patients and preventing problems can help patients feel better, function better and stay out of the hospital.

To do this, the health care providers and patients need to communicate well with each other. Patients can communicate electronically with their providers any day, by phone or in person by appointment. Providers can help patients keep track of regular testing and treatment needs such as regular testing for H-A1C in a diabetic population, or lung function in an asthma population. By reducing risks, knowing the population and individuals, and having an accessible, seamless system with patient-centered decision-making, patients can stay healthier.

Not surprisingly, this lowers costs. It is less expensive to stay healthy than to treat advanced disease. It costs less to receive treatment at home or in clinics than in a hospital. Government payers and commercial insurers are increasingly paying providers for quality care and for managing the cost of care a person receives. This, too, encourages health care providers to use population health approaches.

Using data-driven strategies for change

By identifying people who are at high risk for diabetes and cardiac disease, providers can offer annual screenings to detect risk factors such as high cholesterol, obesity, high blood pressure and high glucose, and create programs to address these issues.

Wellness programs to benefit populations

Providers can offer a range of programs to support the health of a population. Programs can include tobacco cessation, weight management, community-supported agriculture (CSA) programs for fresh food, free fitness center memberships and more.

Central focus on care coordination

Care coordinators are a vital part of managing population health. These certified professionals are responsible for helping a population manage and maintain its health. They provide information and ensure patients get the appropriate care. They work together with the patient and provider to promote wellness.

By focusing on the needs of like groups, and providing information, encouragement, testing, treatment and care management, people can often stay healthier and happier, at a lower cost. And – it can be done more efficiently and effectively. That is population health.

Apryle Pickering, MMA, MPH, is manager of population health and government affairs at Providence Western Montana.

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