Population health management requires new capabilities for improving health and health care for defined populations.  We have identified seven core capabilities that are essential for organizations across the spectrum of clinical care, public health, and community services.  By building these capabilities now, you can help assure that your organization or community is positioned to engage in population health management.

7 core capabilities

Seven Core Capabilities for Population Health Improvement

1. Identify populations. The first core capability is the ability to identify the populations you serve. Depending on the nature of your work, your population may be the members of a patient panel, the members of a particular health plan, beneficiaries of a particular payer such as Medicaid or Medicare, or the residents of a community. Answering this question requires information to identify population members based on defined criteria such as age, sex, health status, utilization patterns, health coverage type, geographic location, and other factors.

2. Assess health risks. The second core capability is the ability to determine the health risks present within specific populations. The objective is to examine the health status of the population compared to appropriate goals or benchmarks, and identify opportunities for health improvement.   In determining risk it is important to  look beyond strictly clinical data to understand the social and environmental factors that influence the health of the population. It is often helpful to classify (or ‘stratify’) patients into groups based on level of risk as the basis for defining care needs and optimizing care models.

3. Define care needs. The third core capability is the ability to define the care needs of specific populations based on examination of their health risks and related factors. Here it is important to consider the complete spectrum of care needs across the clinical and community setting. This is important not only for the populations you serve, but also for your organization, so that you can understand where your scope of influence on population health begins and ends. This may require some research on recommended care models for specific populations. 

4. Optimize care models. The fourth core capability is the ability to continually optimize your care models for specific populations. Here as in #3, you can use research on recommended care models to identify areas where your current model is strong or needs improvement. You can also tap into the knowledge within your organization to identify opportunities for improving care. It is important to be forthright about defining care elements that your organization or unit cannot provide. Addressing these gaps in care is a key success factor in population health improvement. 

5. Collaborate for impact. The fifth core capability is collaboration for population health improvement. Few if any organizations today can provide the full spectrum of services and supports required for improving the health of specific populations. Clinical and community partnerships are essential. One key to building and sustaining these types of partnerships is to design them around specific populations within a clearly defined care model and appropriate performance metrics. A second key is to reform payment to support these kinds of partnerships. 

6. Assure quality. The sixth core capability is to assure quality for defined populations. Quality assurance is obviously important for any program of health service or support. In population-based initiatives, it is important to define quality assurance processes for specific populations across the continuum of care. In this context it is important to assure that each service provider has appropriate quality assurance procedures and measures in place. In addition, it is important for all of the involved service providers to understand the total quality profile for the population, so that each provider can define quality improvement strategies that contribute to better total quality for individuals in the population.

7. Demonstrate value. The seventh core capability is to define and demonstrate value to key stakeholders. Here we define value conceptually as quality and outcomes relative to cost for the defined population. In a given initiative the range of stakeholders may include the population members, service partners, payers, funders, regulatory agencies, public officials, and others. The definition of value is likely to vary across stakeholders, and in some cases, value may be defined in ways that are conflicting or impossible to meet. Given this risk, we strongly encourage health service providers to proactively define their value proposition in terms that make sense within the specific context. This may require new capabilities for measuring dimensions of access, quality, utilization, outcomes, and costs for specific populations. Building these capabilities now is one of the most important things your organization can do to position itself as a value leader in a population health.

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