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Reaching the end game: Total population health


The National Quality Strategy, issued in 2011, formally adopted the triple aim of better care, healthy people and communities, and more affordable care. It also channeled health care’s collective consciousness toward total population health. The Institute of Medicine’s Roundtable on Population Health Improvement adopted a working definition of population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” (Kindig and Stoddart, 2003.)

Advancing population health means improving the health outcomes of communities defined within a geographic area at the local, health plan, health system, regional, or national level. Multiple determinants of health affect population health, including one’s social environment, physical environment, genetics, behaviors, and availability of medical care. Income, education, employment, social supports, and culture comprise the social environmental factors that exert a significant influence on health, as do such physical environmental factors as urban design and availability of healthy food, clean air, and water. Habits, health-promoting behaviors, spirituality, and resilience of a population also shape the health of a community.

Like a seesaw, health care is balancing in a precarious state of transition from acute-illness treatment and payment on one end to the future state on the other end; the latter reflects a greatly reduced need for high-acuity healthcare services and offers rewards for keeping people well. As care migrates to population health management, the balance is shifting to reduce the traditional demand for disease care, and is being replaced by interventions that occur before acute illness and disease progression take hold. Healthcare organizations have hovered over the middle of the seesaw by focusing primarily on high-risk patients. Tipping the balance now is the imperative to address preventive and chronic care needs across an entire population.

The impetus to get to the future state is creating an economic imperative to alter behaviors of patients, providers, and payers. Since hospital payments were redesigned in the 1980s, we have chased healthcare illness dollars around diagnosis-related groups. We have fashioned quality-improvement efforts to follow the ups and downs of payments that reward providers and institutions for better quality and penalize them for deviations from expected outcomes. The era of population health management demands organizations take on risk, which creates new headaches for any group that has yet to develop a population health strategy. New partnerships are developing across geographic communities among payers and providers who want to ensure a change from delivering care in an outdated illness model to managing the health of a population.

The Affordable Care Act supports enhanced population health by increasing access to care, expanding insurance coverage, and rewarding higher quality. It also incentivizes providers to take responsibility for better health outcomes and eliminates cost sharing for some screening and preventive services. Employers can incentivize employees with reduced premium payments or cash bonuses to participate in education programs, early detection, prevention, and health-promotion activities. These changes help foster greater engagement among providers, hospitals, employers, and employees. They help individuals make choices leading to meaningful lifestyle changes for better health.

Successful population-health management relies on health data analytics that are useful for early detection of health risks, identifying care gaps, analyzing electronic health data, and creating information-driven care plans, which also can help identify obstacles that might prevent a patient from achieving health goals. Using this information, healthcare providers can better coach the individual, offering the most effective incentives to get the intended outcomes and more easily track and trend results.

Some have called for creative destruction of health care as we know it, in order to reduce the illness burden and reach population health that’s aligned with payment reform. None of this will be easy. Challenging the status quo never is. But if any of this sounds familiar, it might be because we can reflect on the writings of Florence Nightingale, who expected nurses to be the moral agents of health by addressing cleanliness, warmth, clean air, and water. She advocated making health contagious and infectious. Had she been able to tweet in 1894, she might have advised her colleagues that “Preventable disease should be looked on as a social crime,” “It is cheaper to promote health than to maintain people in sickness,” and “Money would be better spent in maintaining health in infancy and childhood than in building hospitals to cure diseases.”

Nurses have followed her advice by advancing roles promoting population health. We keep patients and families healthy at home, help the elderly age in place, promote immunizations, and teach injury and accident prevention. We provide home visits to assess high-risk environments and devise creative solutions to reduce exacerbations of chronic conditions and promote healthy behaviors. With population health as the new endgame, nurses are in a prime position to carry out the reconstruction of a new care-delivery model that becomes a new business model. We only have to know when to help tip the seesaw in the direction of promoting and maintaining health. It will require us to change, too.

Selected reference

Kindig D, Stoddart G. What is population health? Am J Public Health. 2003;93(3):380-3.

10 Comments. Leave new

  • Anne Llewellyn
    June 15, 2014 11:56 pm

    This is an important article and really supports the movement to have a Chief Nurse for Public Health to elevate the authority and visibility of this position. If we want to improve health, control costs and empower consumers ,we need to have nurses at the grass roots level. Please take a minute to read H.R485, the National Nurse Act of 2013 you can find it at http://www.nationalnurse.org

  • Great article and makes the case for National Nurse to help create strategies of change. This concept strongly supports the practice of ambulatory care and home care nurses in population health and strong transitions from acute care enviroments ! Finally, a broader , more effective system of health care delivery just might happen ! E.Mary

  • Nurses have always advocated for health – physical, mental and spiritual. If only those with the “control” would give us the opportunity to do what we do best – teach patients how to prevent complications of their disease process and teach how to possibly avoid the disease in the first place. I hope we continue on this path for all our citizens including those with mental health issues.

  • Manjula Paul
    June 13, 2014 3:23 am

    WOW,What a great call for a “Change” A change that requires us to translate our care /prevention activities to measuring health and well being outcomes.Connecting individual care to population health and considering factors influencing health (social determinants), involving patient ,family and community as a care team members and integrating nursing care into interdisciplinary approach would promote continuum and safe transition.Theory based practice models support population health initiatives

  • What a great idea. I am in support of National Nurse

  • What a great idea!! Now we need a National Nurse to take it and run with it and help us solve many of the health care issues and reduce costs of chronic diseases.

  • Remember the nursing care plans which are based on the “treatment of human responses to actual and potential health problems”? Nursing is about treating the present and preventing future illness. How many care plans are “at risk for…”? The answer is numerous. The common denominator here is the nurse and preventative care! Nursing should have a leader that is in support of this such as a National Nurse for Public Health.

  • Rita Batchley RN, The Nurses Nurse
    June 11, 2014 8:52 pm

    A national nurse will promote what Florence advocated for from the beginning: nursing leadership that sets the gold standard of professionalism and the national health care goals of America. After all, an ounce of prevention is worth a pound of cure.

  • What a great idea! This could facilitate communication among nurses and regions to assure best practices!

  • A National Nurse will advance the Public Health Priorities and serve as inspiration for all nurses working in Public Health and patient education. Support the creation of a National Nurse like the Surgeon General.


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