Idea Gallery: What is Population Health, Anyway?

Oct 1, 2014, 12:46 PM

Idea Gallery is a recurring editorial series on NewPublicHealth in which guest authors provide their perspective on issues affecting public health. Today, Jeffrey Levi, PhD, Executive Director of Trust for America’s Health (TFAH), writes about the importance of identifying and implementing policies and practices that can benefit health across all populations.

I go to countless meetings where people debate the meaning of “population health”—often for hours and with no resolution.

What’s become clear to me is that no matter what perspective we’re coming from, our actual goal for population health is the same. We want to improve the health of Americans.

But, at the end of day, the problem may be that the hang up on a clear definition is getting in the way of solving one of the health system’s most pressing problems: How do we get the different silos of the system to work better together and improve health inside and outside the doctor’s office?

Because this is so vital, the Robert Wood Johnson Foundation has supported an upcoming National Forum on Hospitals, Health Systems and Population Health, which will go beyond semantics to specifically identify policies and practices that can benefit health, no matter what population you’re talking about. Some of the below examples will be highlighted at the National Forum.

Hennepin Health, a Social Accountable Care Organization (ACO)

When Minnesota expanded Medicaid to a poor, childless adult population in Hennepin County, the relevant parties formed a social ACO, called Hennepin Health. The ACO is comprised of Hennepin County Medical Center; NorthPoint Health and Wellness (a Federally Qualified Health Center); Metropolitan Health Plan; and the county’s Human Services and Public Health Department (including Health Care for the Homeless, the county’s Mental Health Center and other social services). The County has a global budget to spend annually, and the partners take on all the risk as they bill the plan per service and then, at the end of the year, split the gains or losses.

Hennepin Health serves more than 6,000 enrollees. Of this group, 45 percent have chemical dependencies, 42 percent have mental health needs, 32 percent have unstable housing and 30 percent suffer from at least two chronic diseases.

For every patient, the ACO meets them in their home, workplace, shelter or wherever else is needed. They typically first work to get a patient into stable housing, and then start on the prevailing health issues. One of the first actions they took was stationing mental health specialists directly in the clinic. As a result of connecting patients intentionally with the community resources and social services they need, Hennepin Health reduced emergency department visits by more than 20 percent. In total, the efforts have allowed the county to reinvest more than $1 million in savings to develop innovations that fill additional service gaps.

Community Connectors & Molina Healthcare

Molina serves Medicaid, Medicare, CHIP, Marketplace and dual eligible beneficiaries. As is sometimes the case with these populations, they face particular challenges—among them homelessness, chemical dependency and joblessness—that make it harder for them to follow a doctor’s advice, which can lead to a rapid decline in health or prevent them from seeking appropriate care in the first place.

Because of this, Molina created a new position called Community Connectors. They are individuals who “serve as liaisons between patients and clinicians and take a personal approach to assessing needs and assisting the treatment team with coordinating members care.” They work with individual members and go beyond the clinical setting to connect patients with vital social services, such as safe, affordable and healthy housing.

The program has shown dramatic results. In New Mexico, the program has demonstrated savings of $4,564 per enrollee and reduced usage of health care services.

Boston Children’s Hospital’s Community Asthma Initiative (CAI)

Boston Children’s Hospital implemented the CAI—a nurse and community health worker model—to improve the health of children with moderate-to-severe asthma in targeted neighborhoods. The initiative provides a home environmental assessment and asthma management and medication education, while working with the family and health care providers to remove barriers to asthma control. A nurse also works with community organizations, day care centers and schools to provide asthma education in the community for parents and caregivers.

In fiscal year 2011, the program returned $1.46 to insurers/society for every $1 invested. And, as of October 2012, the program has been credited with an 80 percent reduction in the percentage of patients with asthma-related hospital admissions and a 56 percent reduction in the percentage of patients with asthma-related emergency department visits.

These examples bridge the divide between the health care system and the community, including all the social supports and other community assets that can help people prevent and manage chronic diseases. Population health efforts are breaking down the silos and innovating to provide the services and supports people need to be as healthy as possible. And, the really good news is that there are pockets of success, where people are healthier, happier and more productive, and providers and communities have reaped savings by working together.

In short, it’s time to figure out how we can bring promising models to scale and pull the right policy levers to provide the resources and support that will help these programs reach more and more people.

>>Join the National Forum on Hospitals, Health Systems and Population on October 22-24 in Washington, D.C.

This commentary originally appeared on the RWJF New Public Health blog.