Moving Forward on Population Health



For many years, within the public health sphere there has been discussion about the need to address health promotion and disease prevention from a broader context that considers the community as a whole: the environment and inputs that allow people to make healthy choices and to be healthy. The idea is that we should be thinking in terms of population health – that is, health outcomes of a group of individuals, including the distribution of such outcomes within the group – rather than responding to the health of individuals from a purely medical treatment point of view. Although it has been clear to many in public health that this is the logical way to look at health systems, we could not make a lot of progress because of the strictures of the funding system.

I am now seeing a shift. Finally, because of health reforms that have allowed a new flexibility in funding streams, we are able to talk about making the integration of public health and medical care a reality.

There are two main reasons for this shift that are taking place in the broader scheme of health care. First, the concept of the patient-centered medical home – taking a team-based approach within providers’ offices to coordinated treatment and prevention – has been taking hold. Medical practices are being asked to demonstrate high levels of patient satisfaction, adherence to standards of care, and improvement in health outcomes. A factor in this shift is that the Patient Centered Medical Home (PCMH) is a key strategy within accountable care organizations, which are now being held accountable for costs and outcomes of the populations they serve. Providers now have a financial incentive arrangement to keep costs down and produce better outcomes – for example to ensure that patients are getting the care they need to reduce hospital readmissions.

The second factor is the availability of federal funding for state innovation grants that enable the public health sphere to support efforts to build healthy communities, such as the work JSI is doing for Mass in Motion in three Massachusetts towns.

As a result, there is now an opportunity to adopt principals of population health management to build new models of health promotion by looking at health states, needs, and outcomes within communities, and developing interventions based on those findings. It lets us provide care within the broader scheme of work, home, play, life, rather than just when the patient walks in the door of a clinic.

The state of Maryland has offered terminology for what it is calling a new multi-payer patient centered medical home: the “community integrated medical home.” The CIMH vision is a transformed health system that integrates patient-centered primary care with innovative community health initiatives. We are now ready to make a reality the community-integrated medical home, in which primary care is working together with local health departments. In this model, local public health staff identifies and responds to hot spots for low health status or high rates of emergency department use and hospital readmissions, and connects high risk patients to community-based supports.

How does this work on the ground? Let’s take the incidence of diabetes, for example, a disease that is becoming an epidemic in the United States. When a person comes into a clinical setting due to symptoms of out of control blood sugar, they need medical intervention: insulin shots. With PCMH, we would have, within that same office, a nutrition counselor, and even a behavioral health specialist, who can help the patient understand why they may be resisting the needed intervention – that is, the insulin shot. If necessary, the patient can also meet with an endocrinologist, or a cardiologist. Specialists are onsite or affiliated to make the referral seamless and coordinated. The medical home helps improve care and reduce costs by reducing emergency room visits and avoidable hospitalizations related to complications with diabetes.

Taking the PCMH to the next step, we would identify, through GIS mapping,  the community that is producing a high proportion of people with diabetes, and then determine what interventions can stop the disease from occurring. When we identify the hot spots, often even down to the neighborhood where there is high risk of diabetes, we can change the dynamics, and really move the numbers.

With integrated health interventions, we make real progress: From responding to emergencies; to establishing medical homes that control the disease better; to figuring out how to reduce diabetes within that hotspot, such as by addressing the lack of parks for physical activity, or the lack of availability of fresh fruits and vegetables.

That’s the next step after the patient-centered medical home. That’s where we are and I’m excited about it because that’s where we have been trying to get over the course of my 25 years in public health, and the pieces are falling into place.

Finally we are able to do work within this broader context. We’ve talked about this possibility for a long time. We have now an opportunity to move forward on population health.


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