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Hospitals across New Hampshire have come together in an unprecedented effort to collaborate and advance population health, using tools and resources from the Pathways to Population Health (P2PH) movement.
New Hampshire’s Foundation for Healthy Communities (FHC), conveners of a “Population Health Peer Group,” began this experiment to align population health efforts and move beyond the walls of individual hospitals to improve health, well-being, and equity in the state. Contrary to the typical competitive, siloed nature of hospitals serving overlapping populations, this group saw opportunity in lining up the assets and priorities across their respective systems.
In 2017, the FHC board of directors launched the Total Population Health Initiative. Their aim is to improve the health and well-being of New Hampshire residents by fostering connections between health care, public health, and the social determinants of health while advancing health equity. When considering the state’s hospitals, the board realized that each defined and approached population health in different ways. They realized that if New Hampshire hospitals aligned definitions and methods, connected siloed activities, and collaborated to share resources and best practices, they would be able to catalyze Total Population Health efforts in the state. This prompted the convening of the NH Population Health Peer Group.
The Peer Group utilized the P2PH Framework and Compass to create shared definitions, understand their current state (individually and collectively), set population health goals, and undertake high-leverage actions. These actions included working more intentionally with people with lived experience, testing methods for building will around population health, and connecting assets across the state.
The Pathways to Population Health (P2PH) Framework
The P2PH Framework helps define key concepts and terms; describes four portfolios of work that contribute to improvement; and identifies the levers vital to accelerating progress. By balancing each of the four portfolios, with a goal of equity at the core, organizations can chart a path to meaningful and sustainable change. The P2PH Compass helps catalogue current population health efforts and identify opportunities to make practical and sustainable advances.
In February 2019, the Peer Group decided to utilize the P2PH Compass to determine their baseline for hospital-based population health work in New Hampshire — as a group and as individual hospitals. They hoped to use this data to identify opportunities to make meaningful and sustainable advances in population health by identifying best practices and promoting them among peers.
Figure 1: Consolidated Compass Results for Participating Hospitals In New Hampshire
Key to Interpreting Figure 1 (For a closer look at the figures, click here)
The Compass results revealed areas of opportunity for both individual organizations and the group. The hospitals achieved a somewhat low score for Portfolio 2 (Social and/or Spiritual Well-Being), a result the Peer Group had expected. New Hampshire hospitals understand the significance of social determinants of health (SDOH), and they have begun to seek out methods of collecting, sharing, and analyzing SDOH data to better understand their populations and connect them to appropriate resources and services. They are, however, still in the initial stages of this work. The Peer Group hopes to learn from the hospitals who scored highest in these areas to share strategies, tools, and successful models.
The lowest of the eight scores was in partnerships with people with lived experience. Their resulting discussions have fostered an appreciation of the enormous opportunity to engage patients and families in improving population health. The Peer Group is exploring how they might work with the Foundation’s Director of Patient and Family Engagement to act in this area.
The experience of taking the Compass, along with subsequent discussions, improved the Peer Group’s understanding of what population health entails, how they measure as individuals and as a group, and how to deploy their collective efforts, assets and resources to improve the health, well-being and equity of their communities.
Lessons Learned
Consider forming a Peer Group with organizations in your region. By working with a group of organizations, you can identify and spread best practices and pool resources toward a shared vision of improved population health.
Consider using the Compass to catalogue current activities and identify opportunities for progress, as an individual entity or with a group that shares the same overall aim. Taking the Compass brings stakeholders together to discuss equity and health in a way that isn’t typically done. It is through this process that existing assets and resources can be identified that weren’t apparent before — sometimes in a partner organization, and sometimes within your own organization’s walls.
Beth Gustafson Wheeler is Director of Population Health at the Foundation for Healthy Communities.
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