Why It Matters
The Pathways to Population Health Framework helps to coordinate efforts to improve health, well-being, and health equity.
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Tools and Resources to Coordinate Your Approach to Population Health

By Joelle Baehrend | Thursday, January 23, 2020

Photo by Barn Images | Unsplash

In recent years, more health care organizations and their leaders have become aware of the myriad and multifaceted factors that affect health and well-being and perpetuate health inequity in the communities they serve.  At the same time, many struggle to find a holistic approach to meet these needs.

Solutions are often siloed and not coordinated across an organization, and community assets are not brought to bear, limiting the positive impact on the community. There has been a collective call for a coordinated approach to better leverage the work underway and unlock the potential for better health for individuals and communities.

Pathways to Population Health (P2PH), funded by the Robert Wood Johnson Foundation (RWJF), was born of a vision of a health care system focused on treating the whole person by building synergy across the domains of population management and community well-being creation. The P2PH movement is unique is that it was developed in partnership and collaboration across multiple organizations as a collective movement towards population health. The P2PH movement set for itself three ambitious goals:

  • Create and align messaging about what the journey to population health entails for health care organizations
  • Build a pathway of support that helps systems identify where they are and where they want to go next, and puts tools and resources from the field in one place.
  • Engage and support health care organizations on the journey to population health

Spearheaded by a group of partner organizations (Institute for Healthcare Improvement, Network for Regional Healthcare Improvement, Stakeholder Health, American Hospital Association, and the Public Health Institute), the P2PH Framework and the Compass Self-Assessment offer a way to see the component parts that work together to create health and well-being, assess the current state of a health care organization’s efforts in each of four domains, and prioritize areas of focus.

The Pathways to Population Health Framework

The four domains, or portfolios, which comprise the P2PH Framework offer a comprehensive view of population health, including: Physical and Mental Health; Social and/or Spiritual Well-being; Community Health and Well-being; and Communities of Solutions. Equity is a foundational concept that runs through all four portfolios. For instance, a team might come together to work in each of the four portfolios to improve the health and well-being of a subpopulation of patients with diabetes in the following ways:

  • Manage diabetes outcomes for a panel of primary care patients (Portfolio 1: Physical and Mental Health)
  • Screen for and address social determinants of diabetes, such as the built environment, food insecurity, etc., in partnership with community social service agencies; establish peer-to-peer supports for diabetes (Portfolio 2: Social and/or Spiritual Well-being)
  • Engage in multisector partnerships to address food insecurity in key neighborhoods (Portfolio 3: Community Health and Well-being)
  • Engage in multisector partnerships to create long-term structure, policy, and systems changes; investment in food banks, parks, etc. (Portfolio 4: Communities of Solutions)

To date, the Framework has been downloaded over 5,000 times; 118 have completed the Compass assessment, 31 organizations have signed on as Pioneer Sponsors, and an additional 300+ have committed to advancing population health as Health Activators.

To this initial set of P2PH resources, we are happy to add new resources and inspiration based on what we have learned from early adopters of the framework about what has worked well, tips for use, and the additional supports that would be helpful to accelerate progress.

  • Case studies: The University of Arkansas for Medical Sciences (UAMS), New Hampshire Foundation for Healthy Communities, and Providence St. Joseph Health have used the P2PH Framework and the Compass to inform their work to improve population health. We’ve gathered their stories to provide real world examples of how to engage stakeholders and gather, review, and act on Compass results.

For example, UAMS gathered executive leaders to complete the Compass assessment and identified Communities of Solutions (Portfolio 4) and the concept of “anchor institutions” as a strategic priority for their population health efforts. They identified a set of actions to achieve their goals, including alignment and standardization of the collection of social determinants of health information across the health care enterprise and a survey of community assets across the state related to food security, transportation, and housing insecurity, and other drivers of health and well-being.

  • Improving Population Health Action Community (Fee-based program): In our discussions over the last many months, the most common request from teams engaged with the P2PH movement has been for deeper support to implement the framework and accelerate improvement on their population health goals.

With additional funding from the RWJF, we are launching the Improving Population Health Action Community, an 11-month action network for health care delivery organizations looking to accelerate their progress toward population health, well-being, and equity. The Action Community will bring together up to 25 teams from health care delivery organizations to learn together and work with expert coaches and faculty. Through in-person and virtual engagement, teams will assess their current state, test improvements, and employ measurement strategies to guide their improvement efforts.

Joelle Baehrend, MA, is an IHI director.

Editor’s note: Join an informational call to learn more about the upcoming Improving Population Health Action Community on Tuesday, February 4 from 2:00-3:00 PM Eastern Time.

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