Shared Language for Shared Work in Population Health

C. J. Peek; John M. Westfall; Kurt C. Stange; Winston Liaw; Bernard Ewigman; Jennifer E. DeVoe; Larry A. Green; Molly E. Polverento; Nirali Bora; Frank V. deGruy; Peter G. Harper; Nancy J. Baker

doi:10.1370/afm.2708

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RE: Shared Language for Shared Work in Population Health
Selina S Vickery

Published on: 15 February 2022
RE: Shared Language for Shared Work in Population Health
Heather R Bleacher

Published on: 17 November 2021
Author thanks and reply to Lloyd Michener's helpful letter
C.J. Peek

Published on: 21 October 2021
A Few Additions to an Excellent Article on Shared Language for Shared Work in Population Health.
J Lloyd Michener

Published on: 15 September 2021

Published on: (15 February 2022)
Page navigation anchor for RE: Shared Language for Shared Work in Population Health
RE: Shared Language for Shared Work in Population Health
Selina S Vickery, Medical Student, The Ohio State University College of Medicine
Thank you to the authors of this work for bringing to light important bridges to facilitate the integration between primary care and population health. The authors identified the important distinction between population health and community health, where community health is the population health goals for specific communities defined by “common interests, problems, fate, or those who live in a common environment, and with whom several primary care clinicians interact over time.” As a medical student, terms such as these often become interchangeable, and it is important, especially moving forward, to be able to differentiate them. By creating clearer definitions for commonly used terms in health care, the training of new physicians will also become more efficient. In this way, newly trained clinicians and public health professionals will not need to relearn local vocabulary with each transition in training.

While reading this informative work, I became curious as to whether there are similar efforts to expand the universal lexicon globally? There are many implications and challenges of expanding health care and aid beyond borders, one of which being language barriers. Do you see the potential for similar universally accepted definitions for common health care terms globally, such as the WHO’s definition of “health?” It will be important for the field of global health to be able to incorporate and translate this publication’s findings to primary care in global setting...
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Thank you to the authors of this work for bringing to light important bridges to facilitate the integration between primary care and population health. The authors identified the important distinction between population health and community health, where community health is the population health goals for specific communities defined by “common interests, problems, fate, or those who live in a common environment, and with whom several primary care clinicians interact over time.” As a medical student, terms such as these often become interchangeable, and it is important, especially moving forward, to be able to differentiate them. By creating clearer definitions for commonly used terms in health care, the training of new physicians will also become more efficient. In this way, newly trained clinicians and public health professionals will not need to relearn local vocabulary with each transition in training.

While reading this informative work, I became curious as to whether there are similar efforts to expand the universal lexicon globally? There are many implications and challenges of expanding health care and aid beyond borders, one of which being language barriers. Do you see the potential for similar universally accepted definitions for common health care terms globally, such as the WHO’s definition of “health?” It will be important for the field of global health to be able to incorporate and translate this publication’s findings to primary care in global settings to facilitate navigation of potential communication barriers.

Another great point by the authors is how collaboration of care delivery and public health-centered roles are designed to improve health of specific populations. Working in a free clinic, we strive to adopt the lenses of both primary care delivery and public health advocacy roles. The unique, underserved and underinsured population frequenting free clinics creates a new niche within community health. Navigating care for these communities requires careful collaboration between direct patient care and increasing access to important resources as the authors discussed in other community settings. It would be interesting to learn how community-oriented primary care may be geared specifically towards free clinics.
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Competing Interests: None declared.
Published on: (17 November 2021)
Page navigation anchor for RE: Shared Language for Shared Work in Population Health
RE: Shared Language for Shared Work in Population Health
Heather R Bleacher, Assistant Professor, University of Colorado School of Medicine, Department of Family Medicine
Thank you to the authors of “Shared Language for Shared Work in Population Health”1 for their efforts to break down barriers to collaboration between primary care and public health. I would like to add to the conversation by suggesting that the role and definition of policy be pulled into the foreground of the framework provided.

In selecting which terms to define, the authors call attention to the “goals”, “realities”, and “ways to get the job done” they have determined to be of fundamental importance for those involved in collaborations for population health. In this framework, the role of policy is presented as one aspect of the social determinants of health, and as a product of public health activities. Naming policy explicitly as a “general way to get the job done”, would place a more substantial emphasis on what is a powerful mechanism to improve (or erode) the health of populations and communities. This adjustment to the framework would open the door for participation from other sectors that profoundly influence population and community health (education, transportation, justice system, etc.). It would also serve to underscore that primary care physicians have a responsibility to advocate for their patients and the policies that support the “Vital Conditions for Well-Being.”2-4

A shared definition of the term “policy” may also be helpful. The CDC defines policy as “a law, regulation, procedure, administrative action, incentive, or voluntary practice...
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Thank you to the authors of “Shared Language for Shared Work in Population Health”1 for their efforts to break down barriers to collaboration between primary care and public health. I would like to add to the conversation by suggesting that the role and definition of policy be pulled into the foreground of the framework provided.

In selecting which terms to define, the authors call attention to the “goals”, “realities”, and “ways to get the job done” they have determined to be of fundamental importance for those involved in collaborations for population health. In this framework, the role of policy is presented as one aspect of the social determinants of health, and as a product of public health activities. Naming policy explicitly as a “general way to get the job done”, would place a more substantial emphasis on what is a powerful mechanism to improve (or erode) the health of populations and communities. This adjustment to the framework would open the door for participation from other sectors that profoundly influence population and community health (education, transportation, justice system, etc.). It would also serve to underscore that primary care physicians have a responsibility to advocate for their patients and the policies that support the “Vital Conditions for Well-Being.”2-4

A shared definition of the term “policy” may also be helpful. The CDC defines policy as “a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions.”5 This particular definition, while it has the benefit of requiring only a single sentence, obscures the practical distinction between “big P” policy (national, state, or city level ordinances that often require legislation) and “little p” policy (organizational practices or rules).6 Greater precision with this terminology would better characterize the range of health-promoting strategies that can fall under the broad category of “policy”. Further, drawing attention to the significance of “little p” policy would be an important reminder that we all must examine how our own institutions contribute to population health or propagate health inequities.7

These ideas may broaden what was meant to be narrow, or split what was intentionally lumped. I look forward to continuing this dialogue as we move forward towards a shared vision of health and wellbeing for all.

1. Peek CJ, Westfall JM, Stange KC, et al. Shared Language for Shared Work in Population Health. Ann Fam Med. Sep-Oct 2021;19(5):450-457. doi:10.1370/afm.2708
2. Win Network. Vital Conditions for Well-Being. Accessed November 17, 2021. https://winnetwork.org/vital-conditions
3. American Academy of Family Physicians. Advancing Health Equity by Addressing the Social Determinants of Health in Family Medicine (Position Paper). Accessed November 17, 2021. https://www.aafp.org/about/policies/all/social-determinants-health-famil...
4. Declaration of Professional Responsibility: Medicine's Social Contract with Humanity. Mo Med. May 2002;99(5):195.
5. Centers for Disease Control and Prevention. CDC Definition of Policy. Updated May 29, 2015. Accessed November 8, 2021. https://www.cdc.gov/policy/analysis/process/definition.html
6. Collins S. Big P, Little P - A Guide to Policy Engagement at All Levels. Accessed 2021, November 10. http://www.amchp.org/AboutAMCHP/Newsletters/Pulse/MarchApr19/Pages/Big-P...
7. American Academy of Family Physicians. Institutional Racism in the Health Care System. Accessed November 17, 2021. https://www.aafp.org/about/policies/all/institutional-racism.html
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Competing Interests: None declared.
Published on: (21 October 2021)
Page navigation anchor for Author thanks and reply to Lloyd Michener's helpful letter
Author thanks and reply to Lloyd Michener's helpful letter
C.J. Peek, Family Medicine Faculty, clinical psychology, University of Minnesota Department of Family Medicine and Community Health
Dr. Michener,
Thank you so much for your thoughtful letter of 9/15/21 regarding our paper “Shared Language for Shared Work…”. I thought of you and the Practical Playbook many times as we came up with those definitions and illustration.

I am very pleased that you commended and thanked us for the paper and the need to move from common confusions to shared meanings. We have hoped the paper would help put that more in the foreground for conversation and evolution. Your letter helps fulfil that hope with its thoughtful observations and suggestions which are now the first entries on suggestions I am pooling for our authors to evolve that diagram. Thank you for those and the excellent references.

You will likely appreciate a balance our authors tried to strike in the definitions offered: A) to reflect today’s realities and common usage among professionals reading this article (what they actually encounter and talk about now when they show up); and B) depicting (proposing really) definitions and relationships among terms that are forward-looking to a better future even if not yet routinely encountered, AND that incorporate ordinary language used by people in communities.

Our authors differed, but finally decided to show definitions and meanings that most persons working in the crucibles of population health would routinely encounter every day—common terms in general widespread use. Because that’s the shared language and workspace they currently navigat...
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Dr. Michener,
Thank you so much for your thoughtful letter of 9/15/21 regarding our paper “Shared Language for Shared Work…”. I thought of you and the Practical Playbook many times as we came up with those definitions and illustration.

I am very pleased that you commended and thanked us for the paper and the need to move from common confusions to shared meanings. We have hoped the paper would help put that more in the foreground for conversation and evolution. Your letter helps fulfil that hope with its thoughtful observations and suggestions which are now the first entries on suggestions I am pooling for our authors to evolve that diagram. Thank you for those and the excellent references.

You will likely appreciate a balance our authors tried to strike in the definitions offered: A) to reflect today’s realities and common usage among professionals reading this article (what they actually encounter and talk about now when they show up); and B) depicting (proposing really) definitions and relationships among terms that are forward-looking to a better future even if not yet routinely encountered, AND that incorporate ordinary language used by people in communities.

Our authors differed, but finally decided to show definitions and meanings that most persons working in the crucibles of population health would routinely encounter every day—common terms in general widespread use. Because that’s the shared language and workspace they currently navigate. One author phrased it as a balance between being "descriptive of the usual now" and "prescriptive of a better later". To fully accommodate what the authors would like to see in the future, we once entertained the possibility of a follow-up paper that proposed such forward-looking improvements as a shift from this status quo, even if not yet that familiar to people out there. At the very least, we can evolve the diagram.

Not coincidentally, your two suggestions were both part of those “balance” discussions.

Social determinants. Some authors said they dislike that term because 1) they are influences not determinants; and 2) it is professional-speak not recognizable to people in real communities. The term you point out, “vital conditions for health” and the cited definition about “conditions in which people live, work and play” are in ordinary language and don’t carry the “you are determined” implication.

After some deliberation, the group decided to retain “social determinants” because it is such a common locution that everyone encounters; if readers didn’t see it, they’d wonder where it is. We tried to clarify with the subtitle “influences”, and ordinary English definitions about conditions and influences where people live, work, and play (with examples of those influences). But I think we need to shift common usage in the directions you and RWJF and others suggest—which would also speak in ordinary language to people in communities.

Public Health. This was a similar challenge to calibrate the paper between familiar commonly encountered reality such as the county, state or city public health office with more evolved things that are much broader in concept. We opted to emphasize the civic core of public health in contrast to the private core of care delivery, knowing neither is a pure type, with an almost limitless “broad zone of collaboration” possible and sometimes taking place.

The definitions you point to are much more inclusive of everything public health no matter who is doing it, which I imagine is where our authors would like to see things land in reality. A shift from public health commonly understood as operationally rooted in civic-based agencies to a more inclusive definition of public health as you say the “science of protecting and improving the health of people and their communities” and “all public, private, and voluntary entities that contribute to the delivery of essential public health services with a jurisdiction”. These definitions open both eligibility and obligation for everyone to be part of it, not just government agencies. That broader concept allows everyone to see themselves in the act and invites shared work, with some kind of division of labor. Yet it preserves the idea of specific communities or jurisdictions.

The suggestions you have made would make the diagram more forward-looking, even as the challenge will remain to balance the forward-looking with dominant usage—what people hear and see around them every day. Maybe there will be a time for an updated paper that goes all-in on the forward-looking picture, even if still unfamiliar in daily experience out there. And having such a paper and diagram might do a lot to make such a preferred future more familiar and recognizable.

Thanks once again for your thoughtful response and appreciation of our start.

C.J. Peek, PhD
Professor, University of Minnesota Department of Family Medicine and Community Health
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Competing Interests: None declared.
Published on: (15 September 2021)
Page navigation anchor for A Few Additions to an Excellent Article on Shared Language for Shared Work in Population Health.
A Few Additions to an Excellent Article on Shared Language for Shared Work in Population Health.
J Lloyd Michener, Emeritus Professor, Department of Family Medicine & Community Health, Duke School of Medicine
To the Editors:

I would like to commend and thank the authors of “Shared Language for Shared Work in Population Health” (1) for their thoughtful suggestions for a common language for collaborations to improve population health – a topic of common confusion, within Family Medicine and without. They offer some hope for improving communication around this vital topic. As family physicians engage in this larger discussion, there are similar activities and shifts in framing and language that may be worth noting.
One is around the language of “social determinants.” While widespread in health care and public health, that language can resonate less well with partners. “Vital Conditions for Health” is an alternative, positive framing that has been suggested (2) especially in work with community organizations and businesses. The Surgeon General’s Report on Community Health and Economic Prosperity (3) is a good example of this usage.
A second is the use of “Public Health.” The usage here reflects the common meaning of governmental public health. But others cast a wider net. CDC Foundation, example, states: “Public health is the science of protecting and improving the health of people and their communities” [emphasis added] (4), while the National Association of County and City Health Officials describes Public Health systems as “all public, private, and voluntary entities that contribute to the delivery of essential public health services with a jurisdiction”...
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To the Editors:

I would like to commend and thank the authors of “Shared Language for Shared Work in Population Health” (1) for their thoughtful suggestions for a common language for collaborations to improve population health – a topic of common confusion, within Family Medicine and without. They offer some hope for improving communication around this vital topic. As family physicians engage in this larger discussion, there are similar activities and shifts in framing and language that may be worth noting.
One is around the language of “social determinants.” While widespread in health care and public health, that language can resonate less well with partners. “Vital Conditions for Health” is an alternative, positive framing that has been suggested (2) especially in work with community organizations and businesses. The Surgeon General’s Report on Community Health and Economic Prosperity (3) is a good example of this usage.
A second is the use of “Public Health.” The usage here reflects the common meaning of governmental public health. But others cast a wider net. CDC Foundation, example, states: “Public health is the science of protecting and improving the health of people and their communities” [emphasis added] (4), while the National Association of County and City Health Officials describes Public Health systems as “all public, private, and voluntary entities that contribute to the delivery of essential public health services with a jurisdiction” explicitly including physicians and community health centers. (5) Healthy People 2030 is an example of the shift, and is framed much more broadly than the work of governmental public health (6). COVID-19 has increased the saliency of this larger view of public health, with health officials needing to work in partnership with communities and health systems – including and especially primary care. When talking with colleagues in state or local health departments, or schools and programs of public health, awareness of the larger meaning of public health may facilitate discussions and finding common grounds.

All of this is both additional support for clarifying our terminology, and as a gentle reminder that shared language requires listening to colleagues outside our field, who may see the world differently, and then engaging in the work of developing language - together. The authors have made an important step in that direction.

Lloyd Michener, MD

1. Peek CJ, Westfall JM, Stange KC, et al. Shared Language for Shared Work in Public Health. Ann Fam Med. 2021; 19(5): 450-456.
2. Vital Conditions for Well-Being. www.winnetwork.org/vital-conditions. Accessed Sept 14, 2021.
3. US Department of Health and Human Services. Executive Summary of Community Health and Economic Prosperity Engaging Businesses as Stewards and Stakeholders— A Report of the Surgeon General. 2021. https://www.hhs.gov/sites/default/files/chep-sgr-executive-summary.pdf Accessed Sept 14, 2021.
4. . CDC Foundation. What is Public Health? https://www.cdcfoundation.org/what-public-health?. Accessed Sept 14, 2021.
5. NACCHO. What is the Public Health System? https://www.naccho.org/uploads/downloadable-resources/Programs/Public-He... Accessed Sept 14, 2021.
6. US Department of Health and Human Services. Healthy People 2030. https://health.gov/healthypeople Accessed Sept 14, 2021.
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Competing Interests: None declared.