Jessica Ochs; Sherry L. Roper; Susan M. Schwartz

Learning Outcomes

By the end of this section, you should be able to:

1.3.1 Examine the paradigm shift in nursing practice from isolated care to the management of populations across health care systems.
1.3.2 Discuss the scope of population health.
1.3.3 Examine the competencies that define the knowledge, skills, and attitudes associated with the domain of population health.

Historically, elements within health care and nursing practice have been siloed, or separated and isolated, from one another. This isolation has resulted in specialists and providers of the same or different institutions failing to communicate with each other effectively or efficiently. For example, suppose Mx. Smith has a primary care provider, diabetes specialist, and heart specialist. The primary care provider and heart specialist may provide care in one hospital, while the diabetes specialist is at a separate clinic. Both the primary care provider and the diabetes specialist may prescribe medications or adjust dosages of the diabetes medications without telling each other of the care plan changes. Mx. Smith may not realize that some prescriptions overlap. Sometimes, providers may initiate a prescription for the same medication using two different brand names, which can lead to unintentional overdosing. Similarly, the primary care provider and the heart specialist could order laboratory testing for the same health problems and might not tell each other that the testing has been ordered and completed. This duplication of care is burdensome to Mx. Smith, who needs to go to a laboratory for bloodwork more than once and pay for testing twice. This lack of communication can be especially dangerous when critical information is not communicated between providers or care facilities (Kelly et al., 2019).

Siloing can also refer to treating one client disease or condition at a time without considering the client’s full picture of health, illness, and social situation. When care is siloed, Mx. Smith’s heart specialist may make recommendations about heart health that do not consider dietary or activity limitations relevant to the health of their kidneys that the diabetes specialist and primary care provider are working to address. Health systems that are not effectively integrated or properly collaborative make health and illness experiences complex for clients (Storfjell et al., 2017).

While modern health care has not solved the problem of barriers between providers and specialists entirely, a shift to focusing on population health and health promotion has prompted changes in all the health professions in order to reduce such siloing. This paradigm shift has led to more collaborative approaches across health care. Providers and specialists are encouraged to work together to improve client outcomes. Work to reduce silos and focus on population health continues, as some barriers still exist between providers, specialists, and clients. With a continued shift in focus to collaboration, integration, health promotion, preventive services, and population health, providers can work together to deliver comprehensive, holistic, and respectful care to health care consumers.

Delivering Population Health

Moving away from siloed systems is a positive change. In a health care system that has siloed practices, providers react to the presence of symptoms and concerns instead of proactively preventing diseases and promoting wellness. Population-based practices in nursing focus on improving the health of populations through proactive approaches, an emphasis on preventative care, and finding opportunities for early intervention. They focus on effectively managing chronic conditions across the health care continuum—the spectrum of health services that includes public health and preventive care, acute care, ambulatory care, and long-term/chronic care in different settings for members of a population (Figure 1.6).

Public health focuses on preventive health measures, health promotion, and population-level health interventions. These measures can prevent disease, reduce the impact of disease, and improve outcomes across a population.
Acute care involves medical care provided in hospitals and emergency departments for sudden or severe health conditions and emergencies. It can also involve disaster management in events such as multivehicle traffic accidents, train derailments, natural disasters, and mass shootings. Delivery of acute care in a timely and effective manner helps prevent mortality and complications among population members.
Ambulatory care includes health services provided on an outpatient basis in clinics and health centers. Annual physical exams and health visits related to management of ongoing conditions are examples of ambulatory care encounters. Ambulatory care can respond to population health needs through offering targeted clinics or specialized health services in areas where select conditions are noted to be common or especially burdensome in a population.
Long-term care services are delivered in skilled nursing facilities, residential facilities, and client homes. People with chronic illness, disability, or functional limitations as well as those receiving palliative care and hospice services obtain support in the long-term care setting. A spectrum of population health outcomes and related goals of care, from minimizing disability to supporting a dignified death, are relevant in this setting. Long-term care can help clients and their families alike. The provision of long-term care supports family members and other familiar caregivers, as some caregiving burdens and stress may be alleviated.

The public healthcare continuum focuses on promotion, prevention, and risk reduction and encompasses the care needs that people have in their lifetimes, who provides care, and the setting in which it will take place. Care needs begin with prenatal care, birth, and childhood. These types of care are provided by fertility specialists, O B G Y N, certified nurse midwife, pediatrics, and family medicine and care typically occurs at a private practice office, birth center, clinic, hospital, or ambulatory setting. People in the middle phases of their lives need preventative care, care for medical events, rehabilitation, and maintenance. These types of care are provided by family, general, or internal medicine practitioners; emergency departments; pre-hospital emergency center; or acute, outpatient, or tertiary care and typically occur in hospitial, ambulatory care, or transitional care setting. Later in life, people need elder care and end of life care. These types of care are provided by long-term care, skilled nursing, or hospice and typically take place in a nursing or long term care facility or through home visits.

Figure 1.6 The health care continuum includes the range of health services that clients will utilize throughout the lifespan. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Thinking about health care as a continuum underscores the idea that health care does not just happen during annual physicals or when someone needs surgery or picks up a new prescription. The concept of the health care continuum affirms that health care services in the public health arena, outpatient settings, hospital units, rehabilitation centers, and family homes are all valid and necessary to population health. On the continuum, health care is comprehensive and coordinated across specialties, providers, facilities, and approaches.

What happens when clients need care in multiple areas along the continuum or move from receiving care in one area to receiving it in another? Transitional care involves coordination of clients as they move between care settings. Such coordination helps facilitate a smooth transition for the client or family and helps avoids harm or errors in the process. Transitional care activities may involve sharing of health care information between settings, client education, and support for needed follow-up encounters. These activities help maintain a critical link between settings, providers, and the client so that all may avoid barriers to good health and care delivery. Implementing transitional care across the population helps support healthy client outcomes, reduce health care costs and readmissions, and minimize the likelihood of adverse events during transitions. For example, a research group conducted a review of interventions to support the transition between pediatric health care and adult health care (Schmidt et al., 2020). For adolescents moving to an adult care provider, transitional care support helps achieve outcomes such as decreases in hemoglobin A1C levels (an important measure of diabetes control), increased participation in education and employment, improvements in disease self-management skills, and shorter lengths of hospital stays. The broad goals of population health align with those of transitional care, as professionals in both areas work to improve health outcomes for populations. Care Transition and Coordination Across the Community discusses this topic in more detail.

Case Reflection

The Care Continuum

Read the scenario, and then respond to the questions that follow.

Alexandra, Sunshine, and Woody receive health insurance through a publicly funded state plan. As the plan only covers pregnant people and children, Christopher currently lacks health insurance. His hypertension is not being treated, and he has not seen a provider in a few years.

Although she has health insurance coverage, as a Black woman, Alexandra is at risk for experiencing adverse pregnancy outcomes due to systemic racism and bias in the health care system. She has had an uncomplicated pregnancy thus far, apart from experiencing frequent viral illnesses due to working in a day care center. She has taken time off to recover from these illnesses and has to take a day off every time she has a prenatal appointment due to the public transportation schedule, so she has missed a great deal of work recently.

Which locations across the care continuum is the Lee family currently accessing?
What locations across the care continuum would the Lee family benefit from that they are not currently accessing?
How could transitional care support help the Lee family?

Nurses drive change in population health through development of innovative programs and initiatives across health care settings. The work of nurses encompasses the entire health care continuum, from prevention to treatment, as well as transitional care to support positive population health outcomes. To recognize the work, leadership, determination, and contributions of nurses who are at the forefront of innovations in population health for clients in hospitals, clinics, residential settings, and communities, the American Academy of Nursing (AAN, 2023) created the Edge Runners program. The AAN annually recognizes nurse-designed models of care that reduce cost, improve care quality, promote health equity, and increase client satisfaction. These projects support moving away from siloed systems in health care and promote population-based practices in nursing. Concepts such as preventive care, early intervention, chronic condition management, and addressing social needs are commonplace among nurse-led population health innovations. As nurses are uniquely positioned to recognize the challenges of navigating several layers of the health care continuum and to address transitional care needs, population health contributions from nurses support client health and optimal population health outcomes. See Appendix E to learn more about the Edge Runners program.

The Role of Nurses in Population Health

Access multimedia content

This video explores the important role of nurses in population health.

Watch the video, think about the noted “visible” and “invisible” contributions of nurses, and then respond to the questions that follow.

How might nurses increase the visibility or public understanding of the “invisible” contributions of population health?
What traditionally “invisible” work of nurses might align with your future professional interests?

Population Health Nursing Competencies

Nurses play a crucial role in advancing population health, but they are not alone in this endeavor. Given the importance of a focus on population health and population-based approaches, several leading organizations have developed competencies for trainees and professionals across health disciplines that direct population health education and skills. These initiatives, aim to strengthen the population health competencies of students entering health. For example, the Public Health Foundation has developed population health competencies to guide workforce development efforts, trainings, program curricula, job descriptions, and other resources to support population health professionals (Public Health Foundation, 2019). Similarly, Duke University developed a competency map that faculty of medical schools, medical residency programs, and physician assistant programs can use to support meaningful integration of population health in education (Kaprielian et al., 2013); these competencies continue to serve as an important framework (Johnson et al., 2020). In 2021, the American Association of Colleges of Nursing (AACN) approved new standards for nursing education, the Essentials, to define the curricular content and expected competencies of students completing pre-licensure and graduate nursing programs (AACN, 2021). The Essentials include a domain focused on population health, as the AACN recognizes the imperative role of nurses in advancing population health.

Some of the competencies related to population health that student nurses are expected to achieve by the time they finish their pre-licensure program include assessing population health data, identifying ethical principles to protect the health and safety of diverse populations, demonstrating effective collaboration and mutual accountability with relevant parties, proposing modifications to or development of policy based on population findings, and articulating a need for change (AACN, 2021). Table 1.1 lists the population health competencies. These competencies help nursing students prepare to address the health needs of populations once they become licensed as nurses. The content and concepts of this textbook, along with the course instructor’s expertise, activities, and assignments, will prepare each student to master the competencies.

Competency	Sub-competency
Manage population health.	Define a target population, including its functional and problem-solving capabilities (anywhere in the continuum of care).
	Assess population health data.
	Assess the priorities of the community and/or the affected clinical population.
	Compare and contrast local, regional, national, and global benchmarks to identify health patterns across populations.
	Apply an understanding of the public health system and its interfaces with clinical health care in addressing population health needs.
	Develop an action plan to meet an identified need(s), including evaluation methods.
	Participate in the implementation of sociocultural and linguistically responsive interventions.
	Describe general principles and practices for the clinical management of populations across the age continuum.
	Identify ethical principles to protect the health and safety of diverse populations.
Engage in effective partnerships.	Engage with other health professionals to address population health issues.
	Demonstrate effective collaboration and mutual accountability with relevant community partners.
	Use culturally and linguistically responsive communication strategies.
Consider the socioeconomic impact of the delivery of health care.	Describe access and equity implications of proposed intervention(s).
	Prioritize client-focused and/or community action plans that are safe, effective, and efficient in the context of available resources.
Advance equitable population health policy.	Describe policy development processes.
	Describe the impact of policies on population outcomes, including social justice and health equity.
	Identify best evidence to support policy development.
	Propose modifications to or development of policy based on population findings.
	Develop an awareness of the interconnectedness of population health across borders.
Demonstrate advocacy strategies	Articulate a need for change.
	Describe the intent of the proposed change.
	Define interested parties (stakeholders), including members of the community and/or clinical populations, and their level of influence.
	Implement messaging strategies appropriate to audience and other interested parties.
	Evaluate the effectiveness of advocacy actions.
Advance preparedness to protect population health during disasters and public health emergencies.	Identify changes in conditions that might indicate a disaster or public health emergency.
	Understand the impact of climate change on environmental and population health.
	Describe the health and safety hazards of disasters and public health emergencies.
	Describe the overarching principles and methods regarding personal safety measures, including personal protective equipment (PPE).
	Implement infection control measures and proper use of personal protective equipment.

Table 1.1 The Essentials: Population Health Competencies and Sub-competencies (adapted from AACN, 2021)

A focus on population health in a nursing program or a practicing nurse’s work does not mean ignoring or no longer managing acute needs. While a shift to a population health paradigm supports the work of nurses in multiple settings, these competencies apply to nurses working in acute or tertiary care settings as well. For example, nurses working in emergency care provide lifesaving interventions, but they can also recognize and address the upstream, population, and system-wide factors that lead clients to require emergency care (Fawcett & Ellenbecker, 2015). Population health competencies allow a nurse to be well-versed in and ready to address the complex needs of clients so they may provide more effective and comprehensive care. The focus on population health within nursing programs and nursing as a broad discipline does not mean that acute or emergent health needs are no longer important. Adopting a population health framework builds on the work of nurses and expands their impact in all settings. The Essentials and their competencies are relevant to the work of nurses across the care continuum, and ensuring that nurses of the future frame their practice through a population health lens helps them address the complex needs and conditions of clients today.