An aging population, increasing rates of chronic disease and the onset of value-based payment structures are among the many drivers that have moved hospitals and health systems in recent years to take a more prominent role in disease prevention, health promotion, and other public health initiatives. In addressing population health, hospitals are taking a more proactive approach to patient care—that is, reaching out to the population beyond the traditional four walls of the hospital to help them manage disease and stay healthy.
Population health can be understood as the measurable health outcomes of a defined group of people, including the distribution of such outcomes within the group. These defined groups may include those who are attributable to or served by a hospital or health care system, those living in a specified geographic area or community or those experiencing a certain condition or disease.
The ultimate goal of population health management is to promote the overall health of a given population while also reducing health disparities by integrating public health principles into health care delivery. Innovative approaches to population health management can not only improve health outcomes and address increased demand for health services, but also improve the patient experience of care. Ultimately, improved population health also can decrease medical costs and allow hospitals to invest in prevention. As established community stakeholders with extensive knowledge and resources, hospitals and health systems are in a unique position to lead on population health management.
Population health resides at the intersection of three distinct health care mechanisms (see figure above). Improving population health requires effective initiatives to: (1) increase the prevalence of evidence-based preventive health services and preventive health behaviors; (2) improve care quality and patient safety; and (3) advance care coordination across the health care continuum.