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"The COVID-19 era is bringing new attention and urgency to people’s social needs, the impact of unmet needs on health, and the importance of partnership among health systems and community organizations."
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Addressing Population Health Amid the COVID-19 Crisis

By Rebecca Goldberg | Friday, May 15, 2020

Addressing P2PH

Photo by InspiredImages | Pixabay

Improving population health can be daunting at the best of times. During a pandemic, it can be even more challenging. The COVID-19 era is bringing new attention and urgency to people’s social needs, the impact of unmet needs on health, and the importance of partnership among health systems and community organizations.

Pathways to Population Health (P2PH) offers a lens through which health systems can consider their population health assets and challenges, breaking population health into more manageable pieces for health care organizations to consider. The framework depicts four interconnected portfolios that represent a comprehensive scope of potential population health-related improvements. The more the activities across portfolios are balanced, the easier it may be to improve population health because each portfolio unlocks a set of relationships, capacities, and levers that a health care organization can use to create change.


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Use the P2PH Compass to catalogue your COVID-19 improvement efforts, develop an asset map to identify activities underway in all four portfolios, and create a plan to develop a balanced portfolio of actions. Ideas for how to address each portfolio during this current crisis include the following:

Physical and/or Mental Health — How can health care organizations improve the physical and/or mental health of individuals within a defined population for whom they feel directly responsible (e.g., patients and/or employees)?

  • Use data to proactively manage and stratify risks of COVID-19 for discrete populations and provide targeted, relationship-based care management for those identified as at increased risk. Henry Ford’s (Detroit, Michigan) COVID-19 Care Kits for disease self-management are an example of this.
  • Integrate behavioral health (screenings, referrals) into interactions with COVID-19 patients.
  • Leverage team-based care to optimize your resources and improve patient outcomes. For example, Bellin Health (Green Bay, Wisconsin) has adapted their care strategy during the current pandemic.
  • Ensure patients have 24/7 access to a care team practitioner as well as access to their electronic medical records.
  • Utilize your patient and family partnerships to identify opportunities for improvement and navigation during this crisis.

Social and/or Spiritual Well-Being — How can health care organizations consistently screen for and address social and spiritual drivers of health and well-being for a defined population (e.g., patients and/or employees)?

  • Identify key socioeconomic and spiritual factors that are influenced by (or exaggerate the impact of) COVID-19. Include these factors in risk stratification to proactively manage patients. Learn about COVID-19's impact on the social determinants of health.
  • Screen for these factors in your patient population, connect individuals to home- and community-based services for their social and/or spiritual needs, and track follow-through and progress.
  • Partner with local social-service agencies, faith communities, housing organizations, and other community-based organizations that have experience with addressing defined social and spiritual drivers.

Community Health and Well-Being — How can health care organizations work together with community partners to improve specific health and well-being outcomes for a place-based population?

  • Collect community-wide COVID-19 health and well-being data. Share data with other organizations and analyze it with an equity lens; stratify and prioritize opportunities with community partners.
  • Partner with community-based organizations and other health care organizations to assess community strengths and assets, health-related needs and disparities, and identify specific opportunities for improvement.
  • Consider how COVID-19 work can align with community benefit programming and resources.
  • SoHum Health (Humboldt County, California) addressed the social determinants of health for seniors in their community by partnering with others.

Community of Solutions — How can health care organizations actively engage in contributing to the long-term, overall well-being of the community as part of their mission and responsibility?

  • Brainstorm nontraditional roles, levers, and assets you can leverage. Instead of laying someone off, how can their strengths be utilized elsewhere to assist with response within your organization or the community? What training opportunities are available?
  • Learn how MaineHealth deployed resources without loss of pay or jobs.
  • Consider local, minority-owned businesses to work with to create face masks or make essential items accessible in the community.
  • Think about community assets — like empty recreation centers and schools — that can be leveraged for COVID-19-related response.
  • Advocate for policies that improve health, well-being, and equity, such as around crisis standards of care and distribution of testing and eventual vaccinations.

COVID-19 has magnified the reasons to address population health. Use the Pathways to Population Health Framework, take the Compass Assessment, and plan next steps using the Getting Started Guide to improve health, well-being, and equity during the pandemic and beyond.

Rebecca Goldberg Brandes is an IHI Project Manager.

Editor’s note: Starting in September 2020, join Bellin Health and others in a nine-month Improving Population Health Action Community of health care organizations facilitated by IHI.

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