Population Health: The Way Forward, Together

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Source: Centers for Disease Control and Prevention.png

Source: Centers for Disease Control and Prevention
Source: Centers for Disease Control and Prevention

"The factors that influence the health outcomes of groups of individuals, including the distribution and equity of such outcomes across various segments of society."

(Definition of population health, adopted from Kindig et al Am J Public Health. 2003;93:380 – 383)

The definition of population health was widely discussed at the 2015 Centers for Medicare & Medicaid Services (CMS) Quality Conference. The event served as a meeting place for major players in the population health improvement process, including patients, advocates, providers, researchers and individuals from programs across CMS, the U.S. Department of Health and Human Services (HHS) and population health organizations like the Centers for Disease Control and Prevention (CDC).

The CDC used the conference as a forum to introduce its recently released Community Health Improvement (CHI) Navigator, a framework and tools to support hospitals, health systems, public health and other community organizations and stakeholders that are interested in improving the health of their communities.

Denise Koo, MD, MPH, Advisor to the Associate Director for Policy at CDC, began by discussing the complexity of what goes into making a community healthy, safe and thriving. Koo also explored the intricacy of measuring such concepts as physical environment, social and economic factors, clinical care and health behaviors – all which contribute to the overall health of communities.

The CDC CHI Navigator can be especially helpful as we move to a value-based health care system.” 

Health systems can use the CHI Navigator’s examples, framework and tools to strengthen their partnerships with public health and other partners, and to conduct needs assessments and to develop community health improvement plans collaboratively, Koo said. For example, the infographic seen above is meant to serve as an educational tool or roadmap for stakeholders or CDC partners engaged in CHI to ensure a common starting point.

The CHI Navigator database can also be used to move from planning to action by identifying evidence-based interventions for inclusion, a population management plan or community health implementation strategies, Koo said.

Koo cautioned that the health care sector can not tackle population health alone. A multi-sectoral collaboration is needed to truly move the needle on community health and well being, and that is what the CDC is aiming to accomplish with the CHI Navigator.

The CDC CHI Navigator can be especially helpful as we move to a value-based health care system,” Koo concluded.

Chisara Asomugha, MD, MSPH, FAAP, Senior Technical Advisor/​Medical Officer at the CMS Center for Clinical Standards and Quality (CCSQ), used the conference as a podium to introduce the work of the CMS Population Health Affinity Group, which is working to develop and incorporate a population health framework into agency policy and programs that align with the CMS Quality Strategy and the National Quality Strategy.

Asomugha opened the floor for discussions around what the participants are currently working on to address population health, since the work is intricately tied to quality improvement efforts. At the end of the session, Asomugha shared the vision for the group – to develop a CMS population health approach that addresses the clinical and social determinants of health – and encouraged each individual to keep that in mind as the linkages between clinical care and community services continue to grow.