Secondary Logo

Journal Logo

Department: Nursing Informatics

Population health management

A formula for value

Cipriano, Pamela F. PhD, RN, NEA-BC, FAAN

Author Information
Nursing Management (Springhouse): February 2017 - Volume 48 - Issue 2 - p 22-24
doi: 10.1097/01.NUMA.0000511918.82892.99
  • Free

In 2010, the Patient Protection and Affordable Care Act (ACA, otherwise known as Obamacare) created a blueprint for a potential sea change that's not well understood by many Americans. The ACA's most visible impacts are the more than 20 million people now covered with health insurance and the shifting of payments to reward quality rather than quantity of care.

What may be less apparent are the imperatives to improve the health of all people and reduce disease burden, embodied in the 2011 U.S. Department of Health and Human Services' (HHS) National Quality Strategy.1 Mandated in the ACA, the strategy embraces the goals of the Institute for Healthcare Improvement's Triple Aim: better experience of care that's accessible, reliable, and safer; healthier people and communities, which addresses the behavioral, social, and environmental determinants of health; and more affordable care through lower costs.

Achieving better health of populations

The Quality Strategy aims are interdependent and rely on a set of six priorities. (See Table 1.) Nurses are very familiar with the priorities that focus on safer care delivery without harm, patient and family engagement in care, and effective communication and increased care coordination. It's time we turn more attention to attacking the leading causes of mortality, enabling healthy living in our communities and creating new delivery models for more affordable, accessible, and equitable care. These actions lead to healthier populations.

Table 1:
Table 1::
National Quality Strategy's six priorities

The first formal definition proposed for population health was “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.”2 Early conceptualizations addressed general health outcomes and were applied to specified geographic regions. Increased attention on the Triple Aim and the National Quality Strategy has prompted widespread use of the term, which now calls for greater clarity in understanding what population health means in clinical settings.

The original Triple Aim pronouncement suggested that a population need not only be thought of in geographic terms, but alternatively as a group of people with a common concern or condition. This allows us to learn about the care experience, health status, and costs of care.3 With growing emphasis on ensuring value in care, use of the term population health management has become a common way that health systems describe active approaches to addressing specific patient populations.

The outcomes of population health management contribute to total population health, which has long been the purview of public health and community officials, as well as business leaders concerned about the economic impact of health. Experts who've studied approaches to defining and measuring population health among public and private providers, as well as stakeholders, strongly recommend the use of “total population health” when addressing goals and objectives for improving overall health status and outcomes.4

Central to improving total population health is recognizing the social, economic, and physical conditions that affect our health. Commonly referred to as the social and behavioral determinants of health, these cover a broad range of conditions, such as education; safety; literacy; access to healthcare; resources to meet daily needs, such as food and housing; a protective physical environment free from barriers and hazards; and health-promoting behaviors and resilience. The saying “the zip code where you live may determine how long you live” is a sad and alarming commentary on the effects of poverty, violence, lack of resources or access to healthy foods, and the absence of clean air and water, which threaten many poor people across our nation.

It follows that achieving better patient outcomes across a population requires integration of the social determinants of health, management of chronic conditions, and effective clinician communication. Nurses are well aware of the effects of these social determinants and are uniquely positioned to deliver services to address these needs.

Neither population health management nor total population health operates in isolation. Early public health nurses embraced Florence Nightingale's vision of a public health system predicated on health promotion and disease prevention. Greater collaboration of healthcare system organizations and public health is needed today to connect the dots across the continuum of experiences from health and wellness to illness and recovery. Hospitals, public health departments, and community leaders can better influence a population's health outcomes when working together.5

Toward a value-based payment system

Healthcare providers, organizations, and payers used to focus on an individual, an episode of care, and garnering maximum allowable payment for services. The reimbursement system rewarded more care that may not always have been necessary or optimal for a particular patient. Since passage of the ACA, HHS has introduced several approaches to move reimbursement from fee-for-service to value-based payments, shifting the onus of risk in part to providers who must take more responsibility for better health outcomes.

This paradigm shift, affecting virtually all providers and organizations, assesses both cost and quality in determining the value of care—a sweet spot for nursing. RNs are the drivers of significant improvements in hospital care and outcomes, as demonstrated in recent reports revealing a 17% decline in hospital-acquired conditions (HACs) between 2010 and 2013. In total, this resulted in 2.1 million fewer HACs, 87,000 saved lives, and $20 billion in savings.6

As we commit to providing value in healthcare, we need to describe and measure it through the patient lens. Value depends on the achieved results and evaluates condition-specific outcomes relative to the costs incurred. Measuring value incorporates all of the services and assistance that help meet a patient's needs for a particular condition, with shared accountability across providers and organizations for total care and any complications. This includes primary and preventive care, as well as disease-focused care that's episodic or chronic.7

When it comes to measuring quality, we're data rich and information poor. We collect data on many quality measures, record patient data from both providers and patients, and attempt to aggregate data from multiple sites and services. However, measurement of value may be elusive depending on the type of data we have and few process measures describe outcomes. Frequently, we use only easily retrievable administrative data, such as billed services; these don't convey the patient's experience or outcomes. We often lack patient-specific quality data and may be limited with data that reflect only a slice of care, rather than a full cycle over a course of treatment.

A stronger health IT toolkit

Population health management requires collecting the right data and applying analytics to improve the efficiency, quality, and value of care. It's crucial that system analytics detect patterns of health risks among populations, not just individuals, so that nurses can intervene to prevent problems or provide early treatment. Tracking of electronic health data is also needed to identify gaps in care and inform information-driven care plans that are longitudinal in nature.

It's time for nurses to step up and lead the move to population health management. Nurses know the power of data to paint the picture of a patient's or population's health status. Nurses are already in key roles coordinating care, managing complex populations and chronic diseases with high illness burden, and keeping track of outcomes. The movement to population health management to produce total population health is tailor-made to fully utilize the expertise and talent of nurses across many settings.

To support these roles, we need robust information systems and a commitment to utilize cutting edge tools that not only track patient data, but also provide syndromic surveillance to uncover trends that contribute to health risks or changing conditions. Systems must also do more than quantify transactions; they must capture and reflect total care and patient experience, as well as outcomes. Our health information technology (IT) systems need to work for clinicians and patients.

Consider these tips to leverage the power of health IT:

  • ensure that systems allow for collection of social and behavioral determinants of health
  • promote work within your organization to address community needs, including your own employees, resulting from social and behavioral determinants of health
  • press for analytics that deliver information to nurses not only in care management roles, but also those organizing and managing delivery services
  • utilize information to tailor interventions to enhance care for specific populations, including those with chronic diseases and for those whom prevention is key to promoting health
  • embrace patient reported data, making sure it's visualized and acted upon
  • understand and advocate for health information exchange and interoperability to have more complete access to patient histories and care summaries from multiple providers
  • work with data analytics professionals to uncover and address trends revealed in a specific population or geographic area that may be affecting a variety of groups in your service areas
  • use data to coach patients to identify their health risks, reach their goals, and achieve greater value in care.

The smart solution

Pursuing value shouldn't be seen as a cost-cutting endeavor. It's the solution to operate our healthcare system in a smarter, more cost-effective manner that best serves patients and communities. Population health management delivers on the promise of care that's truly focused on health.


1. Agency for Health Research and Quality. About the national quality strategy.
2. Kindig D, Stoddart G. What is population health. Am J Public Health. 2003;93(3):380–383.
3. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27(3):759–769.
4. Jacobson DM, Teutsch S. An environmental scan of integrated approaches for defining and measuring total population health by the clinical care system, the government public health system, and stakeholder organizations.
5. Montero JT, Lupi MV, Jarris PE. Improved population health through more dynamic public health and health care system collaboration.
6. Agency for Health Research and Quality. Efforts to improve patient safety result in 1.3 million fewer patient harms.
7. Porter ME. What is value in health care. N Engl J Med. 2010;363(26):2477–2481.
Wolters Kluwer Health, Inc. All rights reserved.