The Ultimate Guide to

POPULATION HEALTH

Background of population health and wellness

What is population health?

Population health helps individuals achieve the highest quality of life possible. It recognizes that health is influenced by social, economic, environmental, financial, behavioral, genetic, psychological, medical, cultural, and developmental factors.

The practice of population health has broadened in the 15 years since David Kindig and Greg Stoddart proposed their definition as “health outcomes [of a group of individuals], patterns of health determinants, and policies and interventions that link these two.” Today, it also encompasses:

Although population health concerns itself with populations, it also focuses on personalized care that puts each individual in the center. To accomplish this goal, private and public agencies collaborate to improve health outcomes and wellness through strategies such as healthy lifestyles, coordinated care, affordable health care, and social support and services.

This approach aligns with the Canadian Federal, Provincial and Territorial Advisory Committee on Population Health (ACPH) definition of population health: “the health of a population as measured by health status indicators and as influenced by social, economic and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development, and health services.” ACPH emphasizes “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.”

What do population health managers do?

Population health and wellness professionals segment populations to provide targeted interventions with the aim of achieving health as defined by the World Health Organization (WHO): “complete physical, mental, and social wellbeing.” They analyze data, considering multiple health determinants such as:

  • Genetics, including age, sex, and race
  • Individual health and behaviors
  • Consumer data
  • Social determinants of health, such as economic factors, employment status, natural and built environment, health care, cultural factors, and social support that can promote or impede optimal health and wellbeing

Along the way, population health and wellness practitioners discover ways to improve the healthcare system, better neighborhoods, and engage individuals. The Centers for Disease Control and Prevention provides training to help individuals improve their population health skills.

Population health versus public health versus community health – what’s the difference?

Population health involves healthcare organizations, community agencies, and wellness companies working together to improve determinants of health with the aim of improving the health and wellbeing of groups of people.

Public health concerns itself with protecting everyone’s health through research, public policy and legislation, education, and social change. These efforts result in less injury and disease, improved health, and lower mortality rates for countries and communities. Examples include healthier built environments, reduced noise pollution, increased access to healthy foods, and effective vaccination programs.

Community health is a subset of public health that focuses on designing and implementing innovative programs that improve the health of specific communities, grouped by geography or based on race or ethnicity. Local agencies, tribal organizations, governmental entities, schools, and non-profits work together to reduce disease and create healthy communities.

What is population health management?

Population health management (PHM) is a strategy primarily used within health and wellness industries to improve health outcomes of specific groups of people. It includes data collection and analytics, risk stratification, care management, engagement, interagency coordination, and outcomes measurement. PHM allows health and wellness professionals to prevent disease, plan treatments and interventions, contain costs, and improve quality of life through multiple touchpoints, including clinical settings, community agencies, and lifestyle management. At times it requires complex care plans that help care managers engage with individuals within targeted populations. Population health tools such as electronic health records and health risk assessments help inform population health companies and practitioners of current health status, risk of future disease, lifestyle behaviors, change readiness, outcomes, and more.

What is integrated population health management?

America’s Health Insurance Plans (AHIP) predicts integrated population health management (IPHM) will revolutionize health care. IPHM relies heavily on interoperability and data analysis. It takes a holistic look at individuals. It combines multiple data points – claims, care management plans, prescriptions, consumer data, biometrics, social determinants of health, community health markers such as walkability scores, and information gleaned from individuals about their health habits and readiness to change – to identify gaps in care, predict chronic disease risk, achieve greater health and wellbeing, and reduce healthcare costs.

What is wellness?

Wellness is more than the absence of disease. It is about “becoming the healthiest you possible,” according to the Substance Abuse and Mental Health Services Administration (SAMHSA). The National Wellness Institute (NWI) outlines six dimensions of wellness necessary for wellbeing and personal fulfillment: emotional, occupational, physical, social, intellectual, and spiritual. Wellsource founder Dr. Don Hall believed that individuals would flourish when all dimensions of health – body, mind, and community – worked together, and he built the first computerized health risk assessment with this philosophy of optimal health. SAMHSA lists eight dimensions: emotional, environmental, financial, intellectual, occupational, physical, social, and spiritual. WELCOA identifies seven areas of wellness: health, meaning, safety, connection, achievement, growth, and resiliency.

Do population health and wellness align?

Population health that focuses on wellness operates on the principle of optimal health for body, mind, and community. It establishes wellness networks that promote wellness components such as social connection, physical activity, healthy diets, and financial wellness. These, in turn, promote physical wellness. On a larger scale, population health and wellness professionals can extend their influence to include businesses and agencies to create community connectedness through events such as free summer concerts, built environments that include green spaces such as nature parks and healing gardens, and a culture that embraces multicultural wellness.

The history of a population health approach to wellness

The concept of wellness is as old as recorded human history. For centuries (perhaps millennia), rulers have had a vested interest in controlling plague and other disease to ensure stable, established populations that could support and defend the kingdom. Chinese and Hindu modalities focused on achieving wholeness. Greeks and Romans emphasized prevention. These approaches to health have influenced modern day concepts of population health and wellness. Concerns about the health implications of social conditions such as unemployment can be traced back at least as far as World War II, according to Dr. Szreter in his article investigating the history of population health. Health disparities between rich and poor were observed at least two centuries earlier. But it wasn’t until the latter part of the last century that wellness became the mainstream way to promote healthier lifestyles in populations.

The role of lifestyle medicine in population health and wellness

Lifestyle medicine operates on the belief that the body can protect and heal itself with healthy habits. Preference is given to therapeutic lifestyle changes as a way to prevent, manage, and reverse chronic disease. The TLC Program for lowering cholesterol is one example of a lifestyle-as-medicine approach to health care. Medicine is used as a supplemental rather than primary treatment. The American College of Lifestyle Medicine focuses on six behaviors to enhance health: A whole-food, plant-based diet; regular exercise; stress management; healthy relationships; adequate sleep; and avoiding risky substance use, including tobacco cessation and responsible alcohol use.

Like the World Health Organization, population health acknowledges that “common, modifiable risk factors” such as substance use, poor diet, and lack of adequate exercise are at the root of many chronic health conditions, including diabetes, heart disease, stroke, and obesity. These perspectives align with lifestyle medicine, which uses healthy lifestyle habits to prevent, manage, and reverse chronic conditions.  

Essential population health management tools

Efficient, effective population health depends on data that is managed by information technology (IT). It should be no surprise, then, that the essential tools for population health companies and other population health professionals include health IT tools:

  • Electronic health records (EHRs)
  • Health assessment data
  • Application programming interfaces (APIs) for real-time data capture
  • Patient registries
  • Health information exchange (HIE) resources
  • Data analysis tools for risk stratification and outcomes monitoring
  • Automated outreach apps, such as email appointment reminders or text alerts to trigger desired behavior
  • Trackers and other patient monitoring devices, including wearables
  • Telehealth (two-way remote services for individuals)
  • Patient portals with personal health records

Many of these essentials were identified by the Patient-Centered Primary Care Collaborative in their October 2013 report. Population healthcare has the added layer of communication systems that connect entities within the healthcare and health plan system that allow them to track referrals, monitor hospital readmissions, manage claims, and interface with extended care facilities.   

The role of a health risk assessment in population health and wellness

Health risk assessments (HRAs) evaluate behaviors and other factors that increase risk for poor health while also helping population health and wellness professionals initiate interventions that can intercept preventable chronic conditions. Identifying change readiness increases the likelihood that an individual will actively engage in an intervention.

HRAs commonly ask about health habits linked to optimal health, such as physical activity, diet, social support, mental health, risky substance use, stress management, and sleep. Many also collect personal health history, biometrics, and socioeconomic influencers. Annual administration tracks health trends, which can give population health and wellness professionals an idea of an individual’s compliance with healthy behavior changes.

Populations most likely to benefit from population health programs

Any population with less-than-optimal health can benefit from population health efforts. Healthy populations are happier, live longer, and are more productive than populations with poor health. Research shows that population health and wellness interventions benefit health in numerous ways. They increase healthy behaviors, decrease incidence of disease, and reduce medication use. Examples of populations that benefit from health and wellness initiatives include health plan members who smoke, employees at risk for diabetes, cardiac rehab outpatients, frail community dwelling seniors, socially disadvantaged individuals without access to healthy foods, and children living in communities without parks and other greenspaces.

Read about how Population Health works for a major wellness company using the WellSuite® IV Health Risk Assessment.

Components of population health and wellness

What are the essentials of population health and wellness?

Data: Population health requires data – both objective data (e.g., personal health history, claims data, and social determinants of health like zip code and income) and subjective data (e.g., happiness, pain, intake of healthy foods, coping, and readiness to change). Data collection also requires an inward look. What resources are available to maximize population health? And what is lacking that could hamper those efforts?

Technology: Technology is essential for effective population health programs. Population health and wellness professionals need a way to collect data, a place to store the data, the ability to securely share data (thanks to the patient access and interoperability mandates by the Centers for Medicaid & Medicare), and a method for analyzing the data and turning it into something useful for positive change. The future of healthcare data analysis may lie in the merger of consumer data and health data – made possible by technological advances. Looking at consumer data helps population health and wellness professionals devise care plans and interventions that fit their population’s engagement style. In addition, intelligent analytics that integrate “soft data” such as chart notes can define actionable steps designed to overcome impediments. Actionable analytics can identify high risk individuals who are most likely to benefit from care plans, as well as the kinds of interventions most likely to succeed. Many interventions will also use technology, such as telehealth, portals, trackers, and email reminders, although some populations need high-touch services, such as in-home visits.

Plans and goals and collaboration: Population health and wellness managers must have solid plans and goals – both short- and long-range – grounded in strategic decisions made in collaboration with healthcare entities, neighborhood groups, community agencies, and government organizations. What will be the priorities for the next quarter, next year, and 5 years down the road? How will success be measured? What will it take for participants to buy in and engage? Positive change is slow to impossible when individuals don’t participate in their health. But a social norm where people are both interested in their health and feel empowered to actively participate in healthful behaviors – such as being physically active daily and eating healthful meals – can create an atmosphere of change. The key is getting individuals to see themselves as active participants in their health and longevity.

How a health risk assessment contributes to healthy populations

For population health and wellness managers

A health risk assessment informs population health programs. It gives health professionals an honest look at their population’s current health practices and risk of future health problems. Armed with that information, they can identify and segment individuals who are at greater risk for future (and often costly) chronic disease and then implement strategies that can promote positive lifestyle choices and improve determinants of health. Follow-up assessments reveal whether the changes have impacted health trends.

For participants

Most health risk assessments include a personal report with analysis of current health and recommendations for each participant which, if followed, should improve health over time.

What data should a health risk assessment collect?

A health risk assessment (HRA) should ask questions to determine current health and happiness, such as height and weight, mood, personal health history, and current treatment. It should also collect information on an individual’s health habits, such as physical activity, stress, social support, diet, sleep, change readiness, and whether they are current with recommended exams and vaccines. This helps to predict risk of future health problems. A robust HRA will also ask about income, education, accessibility, and history of trauma.

Using an HRA to track health outcomes

Population health and wellness professionals should evaluate the effects of their initiatives. One way to receive a tangible measurement is to administer a health risk assessment annually and compare prior assessment results with the current results. There should be improvements in health practices and, as a result, improvements in health and quality of life. As diseases are managed, averted, or reversed, there should be lower rates of hospitalizations and urgent care visits. Employer groups should see higher productivity and job satisfaction.

Why health IT is essential for population health

IT (information technology) may well be the panacea for population health. Data is predominantly housed, exchanged, analyzed, and consumed electronically. Health and wellness professionals, faced with mountains of data, increasingly rely on population health IT to parse and digest data in innovative and efficient ways that allow them to efficiently identify risks, target interventions, increase engagement and behavior change, and achieve desired outcomes with minimal expense. The magnitude of data will continue to increase as Baby Boomers age. By 2029, one in five Americans will be 65 or older. Population health IT innovations accommodate both the numbers of people and the discrete data bits required for personalized care. Douglas B. Fridsma, MD, PhD, FACP, FACMI, president and CEO of the American Medical Informatics Association (AMIA) observes that population healthcare managers “need to use technology and clinical research to take our interventions up a level of magnitude to a population of 1 to 2 million—or even, when we get this right, a population of billions of people.”

In addition, the Centers for Medicare & Medicaid (CMS) has joined forces with the Office of the National Coordinator for Health Information Technology (ONC) to support seamless and secure interoperability. Health IT professionals are valued members of population health teams and wellness and population health managers work toward open, yet secure, nationwide connectivity.

The Health IT Playbook by the Office of the National Coordinator for Health Information Technology is filled with tips and best practices to help health professionals optimize their use of health IT for their population health efforts. The playbook emphasizes the importance of privacy and data sharing. Application Programming Interface (API) calls are a type of integration that allows for secure information exchange between electronic health records (EHRs) and other data systems, such as a health risk assessment or patient portal.

Regulations for population health and wellness managers

Because population health and wellness delves into the realms of health care and personal information, professionals are bound by laws and regulations designed to protect privacy. These include the Health Insurance Portability and Accountability Act (HIPAA), the Affordable Care Act (ACA), Centers for Medicare & Medicaid Services (CMS) policies to improve patient access, and Health and Human Services rules to improve interoperability of electronic health information and care coordination throughout the healthcare system. Other laws and regulations come into play when working with special populations, such as the Genetic Information Nondiscrimination Act (GINA) when working with employee groups, the Annual Wellness Visit requirement for Medicare, NCQA Health Plan Accreditation standards and Healthcare Effectiveness Data and Information Set (HEDIS) measures, and state or local laws.

Learn how Nebraska Medicine relies on health risk assessment data to improve the health of their population. After reviewing health data gathered through their health risk assessment, Nebraska Medicine saw improvements in the well-being of their population on four different levels.

Population health strategies

Having a solid strategy can improve the success of population health efforts. Population health and wellness professionals should take the lead in learning as much as possible about each population to establish a baseline and inform future actions. Assembling a team of interested, committed individuals, such as clinicians, community influencers, technology experts, and government representatives, can make data collection easier as long as they are willing to share their data. Interoperability regulations aim to make this step much easier.

Useful data to consider includes stats on safety, greenspaces, walkability, housing, transportation, disease prevalence, access to healthcare services, alcohol and tobacco use, unsafe sex, health habits such as diet and exercise, education level, employment, social support, cultural beliefs, technology skills, psychographics, and self-reported change readiness. As population health and wellness professionals dig into the data they can both target high risk populations and identify which things are most impactful on the wellbeing and quality of life – both protective and harmful – of their populations. The Commonwealth Fund developed personas for high-need, high-cost patients that can help with population health efforts. It’s then time to design an action plan. Interventions to achieve optimal health may include healthcare pathways and protocols, changes to infrastructure, community programs or classes, or legislative changes.

Cost effectiveness of population health

Population health and wellness strategies prevent disease, increase quality of life, and improve health outcomes. A presentation at a 2016 HIMSS conference quantified the return on investment of population health solutions for chronic conditions such as diabetes and psychological distress. Quantifying a hard-dollar return on investment (ROI) based on disease prevention, management, or reversal can be complicated. But there is another metric that clearly shows the value of population health and wellness. Value on investment (VOI) considers longevity, increased function, improved quality of life, reduced readmissions, fewer sick days, enhanced compliance, improved self-assessment of health, and overall life satisfaction. In their Program Measurement and Evaluation Guide, the Health Enhancement Research Organization (HERO) and Population Health Alliance (PHA) recommend workforce wellness programs report “impact on lifestyle-related health risk factors.” When calculating the value of intervention efforts, population health and wellness professionals should measure both ROI and VOI.

The Centers for Medicare & Medicaid Services Patients First initiative aims to empower patients to be active participants in their health and wellbeing. Our guide outlines four ways to achieve Patients First, value-based care. Download the free eBook.

The future of population health and wellness

How to achieve “patients first” population health management and wellness

The aim of the CMS patients first initiative is to empower patients to be active participants in their health and wellbeing. This requires accessible, high quality, and affordable healthcare services and interventions. Recent examples of patient-focused population health efforts include improved health outcomes for Hispanic Americans and greater understanding of the unique needs of sexual and gender minorities. These accomplishments result from increased understanding of diversity, identifying barriers, increasing transparency, and using data to inform strategies for optimal health outcomes. Some health professionals are participating in a pilot program that gives patients an even greater voice. Called OneNote, the program invites patients to not just read but to contribute to notes in their medical records.

A new workforce wellness model

When workforce wellness began, it was primarily focused on encouraging people to lose weight, quit smoking, and exercise – with the aim of reducing absenteeism and boosting productivity. Today’s workplace wellness models encompass employee quality of life – a comprehensive employee health management approach. Most workforce wellness programs use a health risk assessment, often administered by a third party, such as a wellness provider or health plan. A population health or wellness professional will analyze the data to determine which interventions will be most beneficial for achieving multiple goals, such as improved health, disease prevention, increased employee morale, mental health, reduced healthcare costs, greater loyalty, and increased productivity. Wellness initiatives include on-site wellness clinics offering vaccinations or urgent care services, fitness centers, rooftop gardens that supply healthy foods in the lunchroom, financial wellness counseling, nap pods, mental health days, and a culture of wellbeing. Along the way, they measure success. While some workforce wellness programs see a return on investment in the first year, year one often results in indirect benefits. HERO and PHA recommend the following core metrics: financial outcomes, health impact, participation, satisfaction, organizational support, productivity and performance, and value on investment.

Tips for award-winning wellness.

Precision medicine: the new population health model

According to Dr. Brittany Carter, Director of Health and Research at Wellsource, “Precision medicine is an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.” It’s a term often interchangeable with personalized or individualized medicine since it involves tailoring health care to an individual based on their unique characteristics. Population health and wellness professionals spend much of their time strategizing how they can improve the quality of life for segmented populations. Yet it is individuals who make up those groups. Increasingly, population health and wellness professionals turn to a precision medicine approach to disease management and prevention. The ability to consider genetic differences and how genes impact environmental and lifestyle factors allows for finely tuned interventions that improve positive outcomes. Data and technology bring it all together. The nationwide, million-volunteer, longitudinal All of Us Research Program is actively researching a wide variety of health conditions to see how “individual differences in lifestyle, environment, and biological makeup can influence health and disease.”

Non-traditional population health partnerships

Effective population health requires collaboration between multiple entities. Of course efforts will include health providers, insurers, and social service networks. Who else will be an effective partner to work toward optimal health and wellbeing in targeted populations? Here are a few stakeholders to consider: pharmacies, schools, manufacturers, faith leaders, neighborhood associations, community action groups, clinics, IT companies, consumer marketers, software developers, health risk assessment vendors, dieticians, construction companies, researchers, business owners, farmers, government agencies, and politicians.

Increase interoperability with health risk assessment integration

When considering what population health tools to use, be sure to include health risk appraisals. Also called health risk assessment or HRA, a health risk appraisal gathers a lot of data that can help inform population health and wellness strategies. For example, learning about an individual’s outlook on the future, how much pain they feel, or whether they have a social network can identify psychological distress. Seeing their health habits, such as how many hours they sit and whether they eat too much salt or saturated fat can help predict health problems. Knowing what unhealthy conditions individuals are ready to change helps professionals guide populations into targeted interventions that have the highest likelihood of success. Intervention efforts can have even more impact when population health and wellness professionals use a health risk assessment that allows data to be pulled seamlessly into an electronic health record or other secure data analysis system. Managed care plans are enhanced when HRA data is analyzed in combination with claims and social determinants of health data.

Is integration a right fit?

Tips for engaging populations

Sometimes defining populations and identifying interventions can be a lot easier than earning engagement in population health programs. Population health and wellness professionals must take steps to engage with people as individuals, not just with the collective community. Companies like TriHealth and Welltok have turned to consumer data, using mining methods commonly used in marketing to discover better ways to engage with individuals within their populations. Artificial intelligence, such as machine learning, and other technological advances can make it easier to integrate and analyze large data sets from disparate sources efficiently and effectively.

Care should be taken to connect with the most vulnerable and underserved populations. The American Journal of Managed Care identifies five vulnerable populations: chronically ill and disabled; economically disadvantaged or homeless; rural or geographically isolated; minorities such as the LBGTQ+ population; and children and older adults. Examples of underserved populations include migrant and seasonal farmworkers and urban-dwelling elderly.

Trust can be built by taking time to hear individual concerns and perspectives. Strategies and methods can be adapted as needed after population health and wellness professionals understand community nuances, best methods of communication, health literacy, and logistics of hard to reach populations. A health risk assessment that asks about change readiness is also useful for helping plan needed behavior changes that individuals are actually interested in pursuing.

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