Introduction to Population Health

Addressing health needs across the health continuum through participation, engagement, and targeted interventions for the population.

A framework that identifies the components and stakeholders in population health, including program participation assessment, stratification, interventions, and outcomes, with a cycle of improvement.

Conditions where people are born, grow, work, live, and age, along with systems shaping daily life.

Understanding the characteristics and health needs of a particular population.

Identified small groups of individuals significantly impacting healthcare costs due to unmet social and economic needs, highlighting the importance of addressing the social determinants of health.

Identifying population subgroups based on risk factors to tailor interventions.

Tailoring health solutions to the specific needs of individuals using available resources and plans.

Assessing the effectiveness and efficiency of health programs, including health status, using various evaluation metrics.

Social conditions like socioeconomic status, power, and access to resources are root causes of health disparities. They influence how people benefit from health advancements, even with changing risk factors.

Factors directly linked to disease development, like smoking, weight, or exercise. Often emphasized in traditional medical research.

The argument that social factors like relationships, social positions, and economic structures are key drivers of health.

Individuals with more resources, knowledge, power, and social connections are better positioned to prevent disease and maintain health.

Policies aiming to reduce individual risks should also analyze the underlying social conditions that create vulnerability.

Interventions should consider their impact on fundamental causes, potentially affecting multiple diseases, not just one.

Be cautious about interventions that focus only on intervening variables without addressing the larger social conditions.

Five key areas that influence health: Economic Stability, Education Access & Quality, Healthcare Access & Quality, Neighborhood & Environment, and Social & Community Context.

A framework developed by Teisberg et al. (2020) that emphasizes aligning care delivery with patient experiences and outcomes through tailored interventions focused on capability, comfort, and calm.

Actions taken to address the root causes of health problems before illness arises, often focusing on social determinants of health (SDOH).

Actions focused on individual behavior change to promote health, such as improving diet and exercise habits.

Actions taken to treat existing health conditions and manage complications after illness has occurred.

Using electronic health records (EHRs) to collect and analyze data related to social determinants of health, like income and housing.

Collaborating with local organizations to address SDOH factors like food security and housing.

Ensuring that interventions addressing SDOH are fair and equitable, protect patient privacy, and prioritize resources responsibly.

Ensuring that collected SDOH data leads to meaningful action and improvement in health outcomes.

To improve care coordination, enhance quality, and reduce costs by focusing on specific population needs.

A framework aiming to improve population health, enhance patient experience, and reduce healthcare costs.

A group of healthcare providers responsible for the overall cost and quality of care for a defined population.

A system combining hospitals, primary care, and specialty care to provide coordinated and efficient healthcare for a population.

A primary care model focused on delivering patient-centered and coordinated care, especially for individuals with chronic conditions.

A healthcare payment model rewarding providers for delivering high-quality care at lower costs.

The Affordable Care Act introduced financial incentives for value-based care models, like ACOs, and penalties for hospital readmissions, encouraging population health approaches.

These models all strive to improve care coordination, enhance quality, and reduce costs by focusing on the health needs of specific populations.

Programs or activities addressing community needs to improve access, population health, and provide treatment. These efforts are not for marketing purposes.

Hospitals and other healthcare providers are required to provide community benefit to fulfill their non-profit mission and maintain their tax-exempt status.

Community benefit ensures that healthcare resources reach those who need them most, improving health outcomes and reducing disparities.

A healthcare approach that focuses on individual needs and experiences, prioritizing patient preferences in treatment plans.

A system designed to manage long-term chronic diseases effectively, offering ongoing support and care.

Using technology to deliver healthcare remotely, offering virtual consultations and monitoring.

Technology like fitness trackers that monitor health data in real-time, promoting proactive health management.

The widespread occurrence of chronic diseases in a population.

The significant financial burden associated with managing chronic diseases.

A model that explains why people make health decisions based on their perceptions of susceptibility, severity, benefits, and barriers.

A model describing the stages of change individuals go through when modifying their behavior: precontemplation, contemplation, preparation, action, maintenance, and termination.