Learning Objectives
By the end of this section, you will be able to:
- Define the divisions of population health
- Recognize the goals of population health management
- Discuss the nurse’s role in population health management
The health outcomes of a group of individuals including the distribution of those outcomes within the group is called population health (Silberberg et al., 2019). It takes into account the social determinants of health (SDOH) and the environmental factors that affect the health of the population. Population health is different from community health. The concept of population health is broader, compared to the concept of community health. Population health includes data representing the health condition of a specific group, while community health includes data representing the health condition of the residents in a community. The goals of population health management are to improve clinical care outcomes, integrate care across the delivery system, and address chronic and complex issues. To achieve these goals, nurses play an important role in population health management. As a primary care partner, nurses provide care for individuals and families while also working to improve population health outcomes. As a care coordinator, nurses help coordinate care for patients with complex medical needs. As a community-based facilitator, nurses work to improve health outcomes by engaging with community organizations and stakeholders. Finally, as an informatics specialist, nurses use technology and data to manage population health and improve patient outcomes.
Divisions of Population Health
Population health is a broad approach to health care that focuses on improving the health of entire populations, rather than just treating individual patients. The four main divisions of population health are population involvement, improved health outcomes, patterns of health determinants, and policy revision (Silberberg et al., 2019). Each division plays a crucial role in ensuring the health and well-being of populations, and together, they form a comprehensive approach to population health. Population involvement means engaging with populations to understand the health needs and priorities of the population. Improved health outcomes focus on developing interventions and strategies to improve the health of the population (Silberberg et al., 2019). Patterns of health determinants involve understanding the factors that contribute to health outcomes, such as social, economic, and environmental factors (Silberberg et al., 2019). Policy revision focuses on advocating for policies that support population health.
Population Involvement
A critical component of population health is population involvement, which refers to the active engagement of populations in the design, implementation, and evaluation of programs and policies that affect their health and well-being. Population involvement can take many forms, such as population-based participatory research, patient engagement in healthcare decision-making, and involvement in public health campaigns. By involving populations in the process of addressing their health needs, the resulting solutions are more likely to be culturally appropriate, effective, and sustainable. Additionally, population involvement can promote health equity by addressing underlying SDOH and empowering populations to advocate for their own health and well-being. Overall, population involvement is essential for creating a truly comprehensive and effective approach to population health.
Improved Health Outcomes
Improved health outcomes are the ultimate goal of population health. Measurable improvements in the health status of individuals and populations are referred to as health outcomes. Population health seeks to improve health outcomes by addressing underlying determinants of health and promoting evidence-based interventions (Silberberg et al., 2019). By improving access to healthcare services, promoting healthy behaviors, addressing SDOH, and implementing policies that promote health equity, population health initiatives can lead to improved health outcomes, such as increased life expectancy, reduced rates of chronic diseases, and improved quality of life (QoL). Improving health outcomes is not only beneficial for populations but also has significant economic and social benefits. Overall, improving health outcomes is a critical component of population health and requires a collaborative effort among individuals, healthcare providers, policymakers, and communities.
Patterns of Health Determinants
Patterns of health determinants are the underlying factors that influence health outcomes of populations (Silberberg et al., 2019). Health determinants can be broadly categorized into social, economic, and environmental factors. Social determinants of health include factors such as education, income, and social support networks. Economic determinants of health include factors such as employment, income, and access to affordable housing. Environmental determinants of health include factors such as air and water quality, housing conditions, and access to green spaces. These determinants interact with each other to influence health outcomes, with some populations experiencing greater exposure to negative health determinants and fewer resources to address them. Understanding the patterns of health determinants is critical for developing effective population health strategies that address the underlying factors that contribute to health disparities. By identifying and addressing the root causes of poor health outcomes, population health initiatives can work to improve the health and well-being of all populations.
Policy Revision
Policy revision is a crucial component of population health as policies play a significant role in shaping the social, economic, and environmental factors that influence health outcomes. Policy revision involves reevaluating existing policies and developing new policies that better address the needs and priorities of populations (Centers for Disease Control and Prevention, 2021). This can include changes to healthcare policies, social welfare policies, environmental policies, and other policies that impact the health and well-being of populations. Policy revision requires a collaborative effort among policymakers, healthcare providers, community organizations, and other stakeholders to identify areas for improvement, gather input from affected populations, and implement evidence-based interventions. By revising policies to better reflect the needs and priorities of populations, population health initiatives can help to address health disparities and promote health equity. Overall, policy revision is an essential component of population health, as it can help to create supportive environments that enable populations to lead healthy lives.
Goals of Population Health Management
The goals of population health management are to improve clinical care outcomes, integrate care across the delivery system, and address chronic and complex issues. Population health management is a proactive approach to health care that focuses on the health of entire populations rather than just individuals. The goals of population health management are achieved through a combination of strategies, including risk stratification, care coordination, patient engagement, and population health analytics. Risk stratification categorizes patients by health risk level to help determine allocation of resources. This process works seamlessly with care coordination, population health analytics, and patient engagement. By identifying and addressing the underlying determinants of poor health outcomes, population health management initiatives can help to prevent chronic diseases, reduce hospital readmissions and healthcare costs, and improve overall health outcomes and quality of care (World Health Organization, 2023).
Improving Clinical Care Outcomes
Improving clinical care outcomes is an important goal of population health management. This involves implementing evidence-based practices and strategies to improve the quality of clinical care delivered to patients (National Collaboration Centre for Methods and Tools, 2023). This can include implementing care coordination strategies, enhancing patient engagement, promoting preventive care, and optimizing the use of healthcare technologies. By improving clinical care outcomes, population health management initiatives can help to prevent the progression of chronic diseases, reduce hospital readmissions, and improve overall health outcomes. Additionally, improving clinical care outcomes can lead to increased patient satisfaction, which is an important component of quality care.
Integrating Care Across the Delivery System
Integrating care across the delivery system is a crucial goal of population health management. This approach involves connecting different components of healthcare services, including primary care, specialty care, behavioral health, and social services, to ensure that patients receive comprehensive and coordinated care (Farmanova et al., 2019). By integrating care, healthcare providers can more effectively manage patients’ health needs, prevent duplicate services, and minimize unnecessary costs (Farmanova et al., 2019). This approach also enables healthcare providers to work collaboratively with patients and their families to develop personalized care plans that address their unique needs and preferences (Farmanova et al., 2019). Ultimately, integrating care across the delivery system is essential for improving the overall health outcomes of populations and reducing healthcare disparities.
Addressing Chronic and Complex Issues
Addressing chronic and complex issues is a significant goal of population health management. Chronic conditions, such as diabetes, heart disease, and obesity, are among the leading causes of morbidity and mortality worldwide. These conditions require long-term management and support, making them a significant challenge for healthcare providers and patients. Complex issues, such as mental health disorders and substance use, also require comprehensive approaches to improve outcomes. Population health management addresses these challenges by promoting proactive and preventive measures, promoting patient engagement and education, and providing coordinated and integrated care. The goal is to improve health outcomes, enhance patient experiences, and reduce costs by addressing the root causes of chronic and complex issues through a population health lens.
Nurse’s Role in Population Management
Nurses play a crucial role in population health management. As the primary care partner, care coordinator, community-based facilitator, and informatics implementor, nurses have extensive interactions with patients and their families, making them well-positioned to identify health concerns and provide patient education and support. Nurses’ involvement in population health management can help improve health outcomes, enhance patient experiences, and reduce healthcare costs by promoting preventive measures and proactive management of chronic conditions (Table 4.12).
| Role | Responsibilities | Examples |
|---|---|---|
| Primary care partner | Collaborate with physicians, nurse practitioners, and other healthcare providers to provide comprehensive, patient-centered care to individuals and populations | Perform assessments, manage chronic conditions, provide patient education, and coordinate care with specialists and other healthcare providers |
| Care coordinator | Work with healthcare providers, patients, and their families to coordinate and manage patient care across multiple settings and providers | Assess patient needs, develop care plans, and communicate with providers to ensure that patients receive appropriate and timely care |
| Community-based facilitator | Work with community organizations and other healthcare providers to address social determinants of health that impact patient outcomes | Collaborate with community members and leaders to identify health concerns and develop strategies to promote health and prevent disease |
| Informatics implementor | Use electronic health records and other health information technology tools to manage patient data, monitor patient outcomes, and identify opportunities to improve care | Analyze population health data to identify trends |
Primary Care Partner
Nurses can serve as primary care partners in population health management. As a primary care partner, nurses collaborate with physicians, nurse practitioners, and other healthcare providers to provide comprehensive, patient-centered care to individuals and populations. Nurses can take on a variety of roles in primary care, including performing assessments, managing chronic conditions, providing patient education, and coordinating care with specialists and other healthcare providers. They can also facilitate access to community resources and social services that address SDOH.
Care Coordinator
Nurses can also serve as care coordinators in population health management (Swanson et al., 2020). As care coordinators, nurses work with healthcare providers, patients, and their families to coordinate and manage patient care across multiple settings and providers (Duncan, 2019). They assess patient needs, develop care plans, and communicate with providers to ensure that patients receive appropriate and timely care (Duncan, 2019). Nurses also promote patient engagement and education, providing resources and support to help patients manage their health conditions effectively (Duncan, 2019).
Patient Conversations
Nurses as Care Coordinators
Scenario: A conversation between Nurse Mita Kapoor and her patient Mrs. Rhonda White Feather.
Patient: Hello again, Mita.
Nurse: Good afternoon, Mrs. White Feather. How are you today?
Patient: Mita, I’m afraid that I’m not doing so good (sits down at the desk).
Nurse: Oh, no. I’m so sorry to hear that. Well, you are in the right place. How can I help you?
Patient: Well (pauses and dabs away a tear), I want you to cancel my doctor appointments for next month (wipes another tear). With Ron, my husband, working so much and teaching so many classes, it’s too much for me.
Nurse: Okay (nodding). I am hearing that you are feeling overwhelmed. Is that how you feel?
Patient: It’s just too much. I can’t keep these doctors straight . . . who wants me to do what and go where . . . it’s just too much for an old lady like me.
Nurse: Well, Mrs. White Feather, I can tell that you are overwhelmed and very stressed. I don’t want you to feel like that at all. It is a lot of appointments and information. Ron and I worked together to keep it all straight. Now that he is helping more at the school, he cannot help as much. However, I am still here, and now that I know about this, I can help you to keep it all straight.
Patient: Oh, Mita, that would be wonderful.
Nurse: Awesome. I already spoke with your cardiologist, your nephrologist, and your neurologist. But now that I know what’s going on, I can work more closely with you.
Patient: Mita, I forget who is who and what I’m supposed to tell them.
Nurse: That is a lot to remember. I want to help you with this. I always speak to them every Monday. We go over your weekly lab values and then make adjustments to your plan of care. Now I will call you after I speak with them and go over any changes we need to make. I will also tell you if you have to come in for labs in that week.
Patient: That would be great, Mita. Last week I came in when I didn’t have to. I felt like such a fool (shakes her head).
Nurse: Oh, no! You made that trip for nothing. I don’t want that to happen again.
Patient: Ron was annoyed, but he loves me too much to be upset with me.
Nurse: Well, we are going to work together to make sure that it never happens again. I’m going to make sure you know when to come in and where to go. I will also make sure that all your medications are safe to be taken together.
Patient: (laughing) I remember when you had the pharmacy change my night medicine to liquid because it was easier for me to take. Ron said I was a baby. But that big pill made me throw up.
Nurse: Mrs. White Feather, that is what I am here for. I am here to make sure all your doctors are kept up to date and know what is going on with you. And I’m here to make sure you understand what is happening, when, and why.
Patient: Ron and I joke that you are the best gossiper we know (laughing)!
Nurse: (laughing) I am kind of a busybody. But that’s okay as long as you are safe and everybody knows what’s going on with your health.
Community-Based Facilitator
Nurses can also serve as community-based facilitator in population health management. In this role, nurses work with community organizations and other healthcare providers to address SDOH that impact patient outcomes. They collaborate with community members and leaders to identify health concerns and develop strategies to promote health and prevent disease (Swanson et al., 2020). Nurses can also provide health education, screening, and counseling services to community members and facilitate access to community resources that address SDOH, such as food insecurity, housing instability, and access to transportation (Swanson et al., 2020). For example, nurses can connect their patients with food banks, local charities, or facilities where they can receive free or discounted care. Nurses can work with other team members, such as social workers, to link patients with resources that can help them and their family.
Informatics Implementor
Nurses can also serve as informatics implementor on population health management. In this role, nurses use electronic health records (EHRs) and other health information technology (HIT) tools to manage patient data, monitor patient outcomes, and identify opportunities to improve care. Nurses also work with healthcare providers to develop and implement clinical decision support systems that provide real-time alerts and recommendations to clinicians based on patient data (Swanson et al., 2020). Nurses in this role can also analyze population health data to identify trends, track outcomes, and develop strategies to improve health and prevent disease (Swanson et al., 2020).