We are all talking about ‘population health’ and its implications. Like many providers, we tend to look at population health through the lens of what we know and the ways we have always done things. True care redesign means we challenge conventional thinking and design around what the patient needs.

The definition of population health is evolving, but the term seems to have been most influenced by David Kindig in a paper published in 2002, which proposes the definition: “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” He argues that population health differs from public health in that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two. The graphical picture of this thinking is:

  
Health outcomes are one point on the triangle of the Institute for Health Care Improvement's Triple Aim: improved health outcomes, better patient experience, and reduced cost. Especially for those of us in the health care provider community, we need to understand the determinants of health outside the care we provide, or we will fail in improving the health of a population.

In places where health has really improved there are partnerships with community programs and employers to work on improvements in access to healthy food, cultural changes in the approach to physical activity, access to transportation, and improvements in socioeconomic status. This last one is remarkably important. The next graphic, below, demonstrates how socioeconomic status causes variation in mortality from 786 per 100,000 to 1,045 per 100,000 in the United States.
 

So population health (outcomes) will depend on more than advanced patient-centered medical homes. We need to know the makeup of our population and their needs.

For example, we need to engage in dialogue with our community program partners and with our local Asian, African-American, and Latino patients so that can better understand the social and cultural influences at play and how these affect health outcomes.

One example of non-providers contributing to health is reported in a delightful National Public Radio (NPR) project called Participation Nation. The Boulder Food Rescue does just-in-time food reclamation of discarded fresh food that is delivered by bicycle to places in need. Locally, the Hilltown Elder Network provides support for isolated seniors who live in the Hilltowns of Western Massachusetts.

Achieving improved health outcomes will require us to abandon old ways and weave together an effective network of community activities to improve health outcomes. By getting at the behaviors and inequities that cause poor health coupled with provider networks that bridge to the community through care managers and coaches, we may be able to challenge and change outdated thinking.