What is Population Health Management?

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Population health management brings health concerns into focus and addresses ways that resources can be allocated to improve the health of a group of people called a “population.”

The Centers for Disease Control and Prevention (CDC) describe population health "as an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally." In other words, there are partnerships within community sectors such as public health, industry, academia and local government working together to achieve positive health results.

What Does Population Health Management Mean?

Kimberly Gibbons, DNP, CNM, RN, CNL, a member of the clinical faculty of graduate nursing programs and a capstone coordinator at Southern New Hampshire University (SNHU) said, “Population health management is the process of studying and facilitating healthcare and its delivery in order to create improvement for a population of individuals.”Dr. Kimberly Gibbons with the text Dr. Kimberly Gibbons

According to Gibbons, a population may focus on a smaller group, or may capture a much larger group of individuals who share a common characteristic or problem. “Ultimately, what we are looking at (in population management) is how to improve the care within that population," she said.

The COVID-19 pandemic emphasized what a population might be, according to Gibbons. She said the unusual aspect of this particular pandemic population is that it includes every person on the planet. “However, within the global population, there are subgroups that have been noted to need additional focus. For example, those people with pre-existing medical conditions or those of increasing age.”

The CDC said it is also crucial to bring social and racial injustice and inequity to the forefront of public health.

“In population heath, we constantly ask the question ‘Why?’ Many minority groups have been at higher risk of getting sick and of dying from COVID-19 than other groups," Gibbons said. "Why is this? The pandemic has highlighted the fact that health equity is not a reality in the U.S. We need to find out why this is happening so we can improve this for the future. In this example, one of the things that population health management can do is to bring the problem into focus so we can strive for health equity.”

How is Population Health Different from Public Health?

Public health works to protect and improve the health of communities through policy recommendations, health education and outreach and research for disease detection and injury prevention, said the CDC. It is important that societies work collectively to ensure that people have the conditions in which they can be healthy, and that health and service organizations work together to improve health outcomes within the communities they serve.

“The goal of population health,” Gibbons said, “is to assess the risks and needs of populations, analyze data for the improvement of the care of those populations, and investigate the need for and process to leverage partnerships, in order to improve care of populations. The main goal is to collect and evaluate information in the form of data to inform improvement in healthcare.”

Gibbons currently serves as part of a team developing a new Master of Science in Nursing (MSN) Population Healthcare Management program at SNHU, which she said, “Is designed for nurses, by nurses."

Once a nurse has a bachelor’s degree, the next educational step or rung on the ladder would be a master's degree.

“Master’s prepared nurses are crucial to (the) support of improvement in healthcare," Gibbons said. "A focus on population health at the master’s level provides the academic and clinical skills to do this really well.”

What Are the Components of Population Health?

According to the National Committee for Quality Assurance (NCQA), there are several elements of population health (NCQA PDF source). Six of them are:

1. Care Integration

An Integrated Delivery System (IDS) is described as a network linking healthcare providers through an organized and collaborative network to provide services to a particular population. IDS systems are in place to assist the population being served and manage and improve clinical outcomes and health status.

2. Care Coordination

This component coordinates all aspects of a patient’s care, integrating their care from various providers to ensure proper care is taken to improve health care, as well as to help reduce costs and eliminate excessive or redundant tests and procedures.

3. Teamwork

As inferred, teamwork provides a patient with integrated care rather than fragments of care coming from several views. According to the NCQA, interprofessional teams leverage information, experience, technology and a culture of teamwork provide value for patients and families.

4. Patient Engagement

“Patient activation” indicates the knowledge, skills, ability and willingness of a patient to play an active role in their own health care. A broader concept, “patient engagement” combines the patient’s activation role with mediations that are designed to not only increase their own knowledge but to also encourage positive behavior such as preventative care and regular exercise.

5. Data Analytics and Health Information Technology

Data is essential to population health management in order to identify a population and measure its needs, which allows getting the correct care to the right people.

6. Value-Based Care Measurement

The NCQA said that alternate payment models could adjust fees for service by paying clinicians based on the quality of services provided, rather than simply the volume, and would assist patients with additional services such as transportation, housing and food to improve important population health outcomes.

Why is Population Health Management Important?

Population health management helps to identify the risks and concerns encountered by a population so improvement can be implemented, Gibbons said. Resources can then be allocated through management to provide customized care that best meets the needs of the population and the individual members.

What Does a Population Health Manager Do?

The job description for a population health manager will vary slightly from organization to organization, according to Gibbons. “Generally, the role involves evaluation of data related to the care of individuals and populations in order to identify the need for a plan for improvement,” she said.

While an MSN is not required for some population health management roles, they are considered leadership roles in many organizations. As such, the preparation provided in the MSN education provides the baseline of knowledge, skill and leadership ability that is helpful for highly effective function as a population health manager.

The future of health management, including population healthcare management, looks bright. The U.S. Bureau of Labor Statistics reported that the job outlook for health services managers is projected to grow 32% by 2029 from 2019. And, as of May 2020, the median salary was $104,280.

An MSN in Population Healthcare can help identify ways to connect practice to policy in pursuit of local change. Nurses can learn how non-traditional partnerships among sectors of the community, such as public health, industry, academia, healthcare, local government entities and beyond, can help achieve positive health outcomes.

Nurses with graduate level training in population health can be found in many areas of healthcare. “Population health is not only applied in a hospital, or inpatient, setting. It can also be applied in the community, in businesses or in any place where there are groups of people," Gibbons said.

Population health managers are employed in a variety of settings, and masters’ prepared nurses with education in population health are uniquely prepared to provide this management. “The settings in which nurses can apply population health are limited only by the imagination," Gibbons said. "(The COVID-19) pandemic has shown us that healthcare impacts us every day, in every way. This presents the opportunity to identify populations and improve health in almost every setting.”

Laurie Smith '14 is a writer, editor and communications specialist. Connect with her on LinkedIn.

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