The road map to a strong population health program

Patient-centered care

Population health management can have wide benefits across the spectrum of care, and health systems looking to get into the game should incorporate several key operational goals, according to a new report.

America’s Essential Hospitals brought together a variety of stakeholders over the course of a year, according to a post announcing the report, and those different voices pointed to three steps for building population health programs: have a strong foundation, bring needed resources together and take a community-centered approach to care.

“An important aspect of this work was to understand how hospitals and community partners can collaborate to promote a culture of health and act in meaningful ways to improve health in the community,” Kalpana Ramiah, Ph.D., director of research for America’s Essential Hospitals, said in the announcement. “This work must reach beyond the hospital walls, which makes community partnerships vital to success.”

The foundational steps must include an assessment of community need and how ready a hospital or system is to take on population health initiatives, according to the report. Bring community organizations into the discussions to get a full picture of what needs aren’t being met, and examine hospital culture for its readiness to undertake population health work. A clearly defined strategy should also be a first step, according to the report.

Once a plan is in place, designate a team and hire new staff, if needed. Hospital leaders should take the time to train and educate staff on population health programs and goals, according to the report. Identify community partnerships, too, and bring outside voices into the fold, the report suggests. Some hospitals may need to upgrade or grow information technology offerings as well, as those programs can help measure social determinants of health and screen for particular needs.

The report offers several examples of effective programs that follow similar steps. The University of Vermont Medical Center, for instance, conducts a community health needs assessment with a community-based steering committee involved, according to the report. Patient and family advisers are then involved in each of the population health teams to ensure those needs are being met.

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