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.
Apply a population health and health equity perspective to problem solving.
Calculate and use for decision‐making, key population health metrics and methods.
Leverage publicly available social, place, demographic, and health data to analyze the health of a population.
Synthesize existing tools to design a population-tailored social determinants of health (SDH) screening tool.
Analyze claims data to identify "high cost" patients and build tailored care teams to support patient needs.
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.
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.
Consider different perspectives and demonstrate multicultural competence and inclusive communication while working in diverse groups or sharing in discussion posts.
Explain how structural racism contributes to observed health disparities and apply a health equity framework to class projects and discussions.
Demonstrate flexibility, adaptability, and a growth mindset as we navigate a potentially shifting class environment.