Population Health

Definition: Population Health refers to the outcomes of a group of individuals with similar characteristics—including the distribution of such outcomes within the group—and the role of health determinants. These health determinants can include medical care, public health, social environment, genetics, and individual behavior.¹ According to the Centers for Disease Control and Prevention (CDC), population health allows for health care organizations to collaborate and improve outcomes in the community.²

How does it relate to ACO/PCMH: ACOs and PCMHs are designed so providers can focus more on the health of their patient population and individualized patient care rather than the traditional fee-for-service model. In order to build robust value-based programs, tools such as data analytics and population health are often utilized.³ Population health management entails patient risk stratification, care coordination, patient engagement, and performance reporting, which are all important components for targeting and meeting quality and cost metrics.⁴ By employing these components and understanding which health determinants are most influential for the health outcomes of similar patient populations, health systems can provide higher-quality care and ultimately reduce costs.

Involved organizations/oversight: CDC, CMS, Institute of Medicine (IOM), and other organizations encourage the development of population health programs in organizations providing primary care.^2,5,6 There may be opportunities for pharmacists to develop a population health management program that benefits patients and the organization. Some tactics for developing population health management programs include implementing team-based care (physicians, physician’s assistants, clinical pharmacists, nurse practitioners, nurse case managers, social workers, dieticians, etc.); emphasizing preventive care (immunizations, tobacco screening, weight management, statin therapy for diabetes/CVD, etc.); and outreach for high-risk patients (post-discharge medication reconciliation, pharmacist-led medication management, education, etc.).⁷ Developing and implementing such tactics can prove to be clinically and cost-effective, thus improving the health outcomes of the patients in the community.

Resources:

1. Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380–3.
2. CDC. What is population health? Available at: cdc.gov/pophealthtraining/whatis.html
3. Meyers D, et al. The roles of patient-centered medical homes and accountable care organizations in coordinating patient care. Agency of Healthcare Research and Quality (AHRQ). Available at: https://pcmh.ahrq.gov/sites/default/files/attachments/Roles%20of%20PCMHs%20And%20ACOs%20in%20Coordinating%20Patient%20Care.pdf
4. Health Catalyst. The 6 critical components of population health. Available at: slideshare.net/healthcatalyst1/the-6-critical-components-of-population-health
5. CDC. What are the value-based programs? Available at: cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/Value-Based-Programs
6. Committee on Public Health Strategies to Improve Health; Institute of Medicine. For the Public's Health: Investing in a Healthier Future. National Academies Press; 2012; page 19-21.
7. Zawora MQ, O’Leary CM, Bonat J. Turning team-based care into a winning proposition. J Fam Pract. 2015;64(3):159–64.

Contributing author:

Hindu Rao, PharmD, APh, BCACP
Chapman University School of Pharmacy

Last reviewed 10/24/2023 by Hindu Rao, PharmD, APh, BCACP