Population health focuses on the health and well-being of entire populations. Populations may be geographically defined, such as neighborhoods or counties; may be based on groups of individuals who share common characteristics such as age, race-ethnicity, disease status, or socioeconomic status; or may be attributed to accountable healthcare organizations using a variety of methods. With roots in epidemiology, public health, and demography, a key component of population health is the focus on the social determinants of health and collaborative, holistic, patient-centered and coordinated care to improve population health, identify and reduce health disparities, improve healthcare quality, and reduce healthcare costs. Given the shifting health care environment – from fee-for-service to value-based care – healthcare managers who are able to apply tools to measure, analyze, evaluate and improve population health (one aim of IHI’s Triple Aim) will be well-positioned for positions in health care as the field continues to evolve.

Outcome 1
Apply a population health and health equity perspective to problem solving.

Outcome 2
Calculate and use for decision-making, key population health metrics and methods.

Outcome 3
Leverage publicly available social, place, demographic, and health data to analyze the health of a population.

Outcome 4
Synthesize existing tools to design a population-tailored social determinants of health (SDH) screening tool.

Outcome 5
Analyze claims data to identify high cost patients and build tailored care teams to support patient needs.

Outcome 6
Build an Excel tool to identify patients at high risk for readmission following surgery and develop a tailored care transition plan designed to reduce readmissions.

Outcome 7
Recommend population health management practices (i.e., risk stratification, care coordination, complex care management, patient engagement, cross-sector collaboration), population health delivery models (e.g., medical homes, telehealth), and payment models (e.g., capitation; Medicaid waivers), to achieve the Triple Aim.

Outcome 8
Consider different perspectives and demonstrate multicultural competence and inclusive communication while working in diverse groups or sharing in discussion posts.

Outcome 9
Explain how structural racism contributes to observed health disparities and apply a health equity framework to class projects and discussions.

Outcome 10
Demonstrate flexibility, adaptability, and a growth mindset as we navigate a potentially shifting class environment.