Moving Toward Population Health


As hospitals adapt to value-based payments and delivery models, they are figuring ways to evolve their business models and extend services beyond their four walls.

With the shift from volume- to value-based payment and care delivery models, hospitals and care systems are exploring different paths for organizational transformation to achieve Triple Aim outcomes — better care, better health and lower costs. This involves going beyond the hospital’s traditional role — efforts that are focused on caring and personalizing services for individuals admitted to the hospital — and providing services outside the facility’s four walls to more proactively engage patients and communities.

Achieving Triple Aim outcomes

Population health management is one upstream intervention that can achieve Triple Aim outcomes in a value-based environment. It involves integrating preventive principles into care delivery to improve the health of a defined population. Key elements of population health management include identifying health determinants and addressing modifiable factors, promoting health and wellness, and implementing disease prevention and management programs.

Two AHA guides, “Managing Population Health: The Role of the Hospital” and “The Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnerships,” outline how population health serves as a strategic platform to improve health outcomes. These guides explain how population health resides at the intersection of three distinct mechanisms:

  • Increasing the prevalence of evidence-based, preventive health services and behaviors
  • Improving care quality and patient safety
  • Advancing care coordination across the health care continuum

Population health in a value-based environment

In a volume-based environment, hospitals and care systems implement small-scale, disease-specific programs. As the health care field moves toward more value-based payment approaches, organizations will need to create major systemic and cultural shifts to implement population health management.

Successful population health management programs align mission with services that support a defined population and leverage internal and external resources to address community needs. Hospitals and care systems that successfully developed a sustainable population health management program have fee-for-value contracts that incentivize programs to achieve population health goals. Many health care organizations already are going beyond traditional partnerships and collaborating with community organizations, payers and other clinical care sites to address health care issues.

The second curve of population health

A new Hospitals in Pursuit of Excellence guide, “The Second Curve of Population Health,” highlights six tactical areas that advance population health management in hospitals and care systems:

  • Value-based reimbursement
  • Seamless care across all settings
  • Proactive and systematic patient education
  • Workplace competencies and education on population health
  • Integrated, comprehensive HIT that supports risk stratification of patients with real-time accessibility
  • Mature community partnerships to collaborate on community-based solutions

The guide provides metrics for evaluating population health initiatives and includes several hospital case studies.

Rhoby Tio, M.P.P.A., is a former program manager for the Health Research & Educational Trust. To access “The Second Curve of Population Health” and other resources on population health management, go to