Population health is an approach to care that uses information on a group of patients within a practice—or group or practices—to improve the care and clinical outcomes for those patients. Population health shifts the focus from caring for patients as they come into the office one after the other, to proactively managing a practice's patient panel.
Population health allow a practice to target interventions toward a larger group of patients, using emerging technology and available evidence, to improve outcomes of multiple patients simultaneously. This can lead to greater efficiency.
Population health also involves having a better understanding about the community in which patients reside; factors that might increase health risks, factors that might be protective, and the range of community resources that exist for patients and families and how to access them.
To make the abstract concept of population health more concrete, below are possible applications in the pediatric practice:
- Determine which patients are behind on preventive care visits or immunizations, and send reminder emails/texts.
- Identify children with asthma in the practice, and identify those children in need of flu shots, those with excessive rescue treatments, or those who might benefit from group educational visits. Examine managed care patient lists and reach out to those who have not established care to date.
- Understand the chronic disease incidence in the practice, or health risks that patients and families face, and develop targeted educational interventions and identify relevant community resources. Consider budgeting and contracting based on any newly discovered factors.
Practice Transformation: Look beyond practice walls at needs of children in your community (AAP News, January 14, 2016)
Cusack CM, Knudson AD, Kronstadt JS, Singer RF, Brown AL.
Practice-Based Population Health: Information Technology to Support Transformation to Proactive Primary Care (Prepared for the AHRQ National Resource Center for Health Information Technology under Contract No. 290-04-0016.) AHRQ Publication No. 10-0092-EF. Rockville, MD: Agency for Healthcare Research and Quality. July 2010.
Population Health: Implementation Strategies
Use of an electronic system with structured data fields will allow you to examine your practice population's data much more efficiently. Many Electronic Health Record (EHR) systems have this functionality. If you are not currently using an EHR system, you could consider using a patient registry to capture this information.
A comprehensive health assessment is a systematic collection and analysis of information related to a patient's health, including information about social determinants of health. Most practices already capture data on the patient's medical history and family history, as well as on care that has been provided. However, practices should also be capturing information about a patient's family, social, and cultural characteristics and communication needs if they are not already doing so.
Practices can use the time prior to appointments (such as in the waiting room) or during the clinical intake with assistance from the medical assistant or nurse to have patients and families review and update this information.
Although there is no "standard" comprehensive health assessment, most practices determine the information to include based on its patient population, and develop a template for use. Alternatively, existing tools can be modified to fit a practice's needs. To improve practice workflow, the health assessment tool should be integrated into the practice's EHR system in a seamless way.
2a. Document the patient's family, social and cultural characteristics
Collect, understand and regularly update the patient's family, social and cultural characteristics. The health assessment includes an evaluation of social and cultural needs, preferences, strengths, and limitations. Examples of these characteristics can include family/household structure, support systems, household/environmental risk factors, and patient/family concerns. Broad considerations should be made for a variety of characteristics (eg, poverty, homelessness, sexual orientation, gender, social support).
2b. Document the families/patient's communication needs.
Collect, understand and regularly update the communication needs of the patient and family. Your practice should identify and document whether the patient or family has specific communication requirements due to limited English proficiency (LEP), or hearing, vision or cognition issues.
- Bright Futures Tool and Resource Kit: Includes pre-visit questionnaires and visit-specific supplemental questionnaires designed to capture relevant patient information and clinical data.
There is a vast array of data from the state/local health department, US Census Bureau, the CDC, and through other national surveys that can provide you with a better understanding about the health of your neighborhood and community. Understanding this information will help your practice to identify potential topics to address with patients and families during health supervision visits, and for educational interventions within your practice. The guide below provides you with a list of potential data sources, and tips for obtaining data specific to your community.
It is important not to overwhelm yourself and your team by attempting to improve everything at once. Your best bet is to select 1 or 2 specific things to start with. Some ideas follow:
Examining how you're currently doing on specific measures might help you decide which areas to target first. For example, if you determine that only 30% of 16 year olds are up to date on recommended adolescent immunizations, this might be an area to prioritize.
Develop a listing of patients to be targeted for this intervention, along with their contact information. If your EHR system has captured patient data in a structured and searchable way, and has the ability to pull reports based on this data, it can be queried to pull a list of patients to target for your population health intervention. If you are unsure about whether your EHR system has this capability, it is best to talk to your EHR vendor. Alternatively, a registry can be used to pull this information.
When planning the intervention, consider the communication preferences of patients and families in your practice. What percent of patients actively utilize the patient portal or are subscribers to the practice's Facebook page? Do patients respond to mailed reminders, or are patients/families more responsive to individual phone calls?
Consider obtaining input from youth and families in your practice about the planned intervention and messaging, as youth/families offer unique perspectives about the messages that resonate the most with them.
Implement your intervention by contacting your targeted list of patients and explaining the intervention to them. If your intervention relates to reminding specific patients/families about needed services, patients should be contacted to schedule an appointment. A phone, email, and text script should be developed for your staff to follow. Families are often very grateful and impressed that you care enough to proactively track them down.
If your intervention will be implemented as patients and families come in for office visits, consider utilizing a checklist or EHR alert so that patients can be identified during the pre-visit record review process or upon arrival for an office visit. Patient charts can then be flagged for members of the care team to provide additional anticipatory guidance or education on specific topics.
Evaluate your population health intervention. If a reminder system was used, what was the success rate in actually reaching the patient about the reminder (eg, what percentage of families/patients opened the reminder in the patient portal?), as well as the efficacy rate of the reminder (eg, what percentage of the families/patients abided by the reminder, and received the service?). Gather and assess the data to determine opportunities to improve the reminder process.
Periodically examine your practice's data, ideally on an annual basis. Have immunization rates improved in targeted age groups? Is a higher percentage of patients up to date on preventive care?
The practice should modify the population health intervention as needed, and consider whether it should be implemented on a periodic basis.
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