The people, process, and technology for population management in community health.

Abstract

Population health expands the focus of health care from individual, in-person care to the proactive management of cohorts that can occur asynchronously from a clinical encounter. In its most successful form, the approach segments populations by defined characteristics and promotes outreach and engagement to deliver targeted interventions, even among those who have missed recent or routine care. The triple aim, supported by the Institutes for Health Care Improvement, emphasizes improving the health of populations, cost of care, and patient and care team experience and has influenced new approaches in primary care. In primary care settings such as community health centers, the goal of improving outcomes leverages technology to expand focus from point-of-care interventions to population-level approaches to deliver high-quality preventive services and chronic disease management that benefit entire families and communities. Developments in informatics have introduced technology tools for population management and underscored the need to align technology with effective processes and stakeholder engagement for success. Informed by a review of the literature and observations across multiple implementations of population health strategies in community health, in this conceptual paper, we describe the steps (process), domains of team expertise (people), and health information technology components (technology) that contribute to the success of a population health strategy. We also explore future opportunities to expand the reach and impact of population health through patient engagement, analytics, interventions to address social determinants of health, responses to emerging public health priorities, and prioritization-of-use cases by assessing community-specific needs.

Innovative applications of informatics for families, systems, and health: Introduction to the special issue.

“…A second example of an informatics-based approach with cost implications is the use of population health technologies. A conceptual article by leaders in community health care, Mohanty and colleagues (2021) describe the steps (process), domains of team expertise (people), and health information technology components (technology) that contribute to the success of a population health strategy. Their recommendations for people with expertise across multiple domains (e.g., clinical, financial, operational) operating in well-established teams, processes involved in implementation and sustainment of population health programs, and technology with specific features (e.g., risk stratify patients, integrate external data, manage performance on quality metrics) come from multiple experiences with population health technology implementation in a health center controlled network and a review of the state-of-the-science literature.…”