WHAT DOES POPULATION HEALTH MEAN TO YOU IN YOUR INSTITUTION?

A Summary from Academic Family Medicine Departments

On our 2018 ADFM Annual Survey, we asked the membership, “What does population health mean to you in your institution?” Responses addressed definitions, policies, strategies, processes, and tools related to the clinical, educational, and research implications of population health. Main findings from a simple coding of themes included:

1. The plurality of departments finds a broad definition of population health useful. Attention to the population requires an emphasis on the broader community. Key elements include defining the community, assessing the needs of the community, and improving the health based on commonly agreed upon outcomes. How the broader community is defined is problematic. (Is it payor defined, a geographic entity, or some other construct?) The role of equity and justice is important to some. Attention to the social and structural determinants of health is a key driver for many. Some say population health efforts require advocacy around policy change to be authentic. Additionally, some suggest the rigor of research is necessary.

2. Some departments see their institutional efforts focusing inward on their practices; this is also called population health management or population medicine. A key part of the efforts within these institutions and departments involves community-based multidisciplinary outreach to patients who have poorly controlled chronic conditions or at-risk behaviors aligning with broader efforts to improve the health of all in the community. Advocating for improved resources within the community served by the practice may also include collaboration with public health entities, NCQA certification and alternative payment models such as CPC+.

3. A few departments indicated that their institutions relate population health to the shift to valuebased payment. These departments see population health as a potential cover to excuse predatory practices and “gaming the system.”

4. A small group see their institution as promoting the AAMC definition of population health. In this model, the care delivery system segregates patients based on their needs, with primary care taking on the less complex and working on risk reduction. Our specialty colleagues in this model are enlisted to care for medically complex patients in “specialty medical homes.”

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Figure 1

Integration of primary care and public health: the care continuum.

Reprinted with permission from AAFP Integration of Primary Care and Public Health Work Group. Integration of primary care and public health (Position Paper). https://www.aafp.org/about/policies/all/integprimarycareand-publichealth.html. 2015.

We feel these results highlight how we in medicine are still struggling to separate/integrate/find parallel play with public health. And it is ours to tackle!¹ The AAFP, in the “Integration of Primary Care and Public Health,”² does a nice job of illustrating this struggle.

Family medicine lives at the interface of knowing (1) that your zip code is more important than your genetic code and (2) that you can treat the patient’s disease, eg hypertension or diabetes, while the illness, ie poverty, abuse, prejudice, etc, may kill the person. In our patient-centered approach, we feel the tension of needing to think about context community by community (geographic community or a community defined by characteristics), not person by person, and we see the challenge and paradox of wanting to fix the zip code–level issues while recognizing that compensation systems still largely reward by the person and by the CPT code. With only 3% of the trillions of dollars spent annually on health care going explicitly towards public health, what should our role be?^3,4

Several of our departments have been working to answer this question by engaging deeply with their local communities, partnering with local public health infrastructure and community-based organizations to improve the health of their populations. The University of New Mexico connects the academic health center with the community in numerous ways, including through community health workers in each county serving as a liaison between that community’s needs and the state’s education and legislation initiatives.

At Duke, upon noticing a hot spot in the Medicaid data of high rates of diabetes, obesity, and ER visits in a historically marginalized minority community, the academic health center reached out to existing stakeholders and with this data—as well as the media reporting that there were far more places to buy liquor than fresh vegetables in that neighborhood—the community was able to rezone the area with a tax abatement for a full-service grocery store that hires local community members.

Those interested in learning more about ways that primary care and public health can partner together should check out the Practical Playbook, https://www.practicalplaybook.org/, a resource for helping public health and primary care work together to improve population health.