Population Health Management

Population Health Management2021-06-04T16:28:36+00:00


  • Stephen Horan, PhD is the founding president of Community Health Solutions, a Virginia firm providing research and learning support for community health improvement. He is also  former instructor for the Managerial Epidemiology course in the Virginia Commonwealth University MHSA program.  Over a 30-year career Steve has helped hundreds of organizations achieve better results through effective strategy and practice. He has also been an advisor to consumer groups, nonprofit organizations, corporations, foundations, and public sector leaders. This broad perspective informs his ability to think at the system level as well as the street level, and help people bridge gaps between policy and practice.
  1. Understand key elements of population health management and coordinated care.
  2. Understand factors driving population health management and coordinated care in the evolving health care system.
  3. Understand decision making perspectives of key stakeholders with respect to population health management and coordinated care.
  4. Explore next-stage strategies for creating health opportunity including  business-community partnerships.

Download the Designing for Population Health Management Worksheet

A. Population Health

  • Population health can be defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. 
  • These groups are often geographic populations, but can also be other groups such as employees, ethnic groups, disabled persons, prisoners, or any other defined group.
Some definitions from Healthy People 2030

A health disparity can be defined as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”

Health equity can be defined as “the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”

Social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks.

B. Population Health Management

  • Populations
  • Patients
  • Providers
  • Plans
  • Private purchasers (including employers)
  • Public purchasers (including CMS and DMAS)
  • Policy bodies (Federal, State and Local elected officials and policy groups)
  • Identify populations
  • Assess health risks
  • Define care needs
  • Optimize care models
  • Collaborate for impact
  • Assure quality and equity
  • Demonstrate value
  • Understand health needs for defined populations
  • Promote and support health for defined populations
  • Procure services that support population health with quality and equity
  • Assure health value for the dollar.
  • Identify at-risk populations
  • Prevent injury and disease
  • Promote healthy lifestyles
  • Develop healthy environments
  • Facilitate access to services
  • Engage community stakeholders
  • Facilitate clinical-community collaboration
  • Assure quality and equity
  • Facilitate health-supporting policies.

C. Care Coordination

  • Care coordination involves deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.
  • This means that the patient’s needs and preferences are known ahead of time and communicated at the right time to the right people, and that this information is used to provide safe, appropriate, and effective care to the patient.
  • Resources:
  • Current health care systems are often disjointed, and processes vary among and between primary care sites and specialty sites.
  • Patients are often unclear about why they are being referred from primary care to a specialist, how to make appointments, and what to do after seeing a specialist.
  • Specialists do not consistently receive clear reasons for the referral or adequate information on tests that have already been done. Primary care physicians do not often receive information about what happened in a referral visit.
  • Referral staff deal with many different processes and lost information, which means that care is less efficient.
  • Well-designed, targeted care coordination that is delivered to the right people can improve outcomes for everyone: patients, providers, and payers.
  • Assessing patient needs and goals.
  • Creating a proactive care plan.
  • Monitoring and followup, including responding to changes in patients’ needs.
  • Coordinating care across health care providers.
  • Supporting care coordination with electronic health records.
  • Supporting patients’ self-management goals.
  • Linking patients to community resources.
  • Working to align resources with patient and population needs.
  • Establishing accountability and agreeing on responsibility.
  • Communicating/sharing knowledge.

D. Case Discussion

  • You are the VP for Human Resources at a manufacturing firm with 5,250 employees.
  • Your employee profile leans older (50% are age 40 to 60), and you know from experience there is a growing prevalence of high blood pressure, diabetes, respiratory disease, back pain, and depression.
  • Your CEO has just emerged from a strategy session with a look of concern.
  • Your CEO informs you that the firm is facing intensive competition for business from Europe and the Pacific Rim, and one key competitive disadvantage is your firm’s health care costs.
  • Your CEO asks you to come up with at least five ways to control health care costs for the firm and deliver these by Monday.
  • Working within your small group, adopt a population health management perspective to generate at least five ideas for your CEO.

E. Connecting Business and Population Health

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