Population health management is a relatively new term, but it is by no means a new concept. At its core, it involves studying clinical outcomes within specific groups of individuals, determining how those outcomes are distributed throughout those groups, and understanding the factors that led to those outcomes. Successfully managing the health of a population through preemptive and reactive measures can improve the quality of care and lead to greater patient satisfaction.
Numerous people in the healthcare industry must work together to properly manage population health. A Master of Health Administration degree can open the door to many vital career opportunities that come with a sense of fulfillment, outstanding job security, and competitive salaries.
What Is Population Health Management?
Population health management is a series of processes designed to improve clinical outcomes in specific groups of individuals. According to the Centers for Disease Control and Prevention (CDC), population health is an approach that spans disciplines and departments. Through partnerships between community healthcare providers, educators, health departments, and even governments, population health is designed to improve community outcomes.
Community-based health tends to focus on preventative medical and dental care, the management of chronic conditions, and ensuring that every healthcare dollar spent has as much positive impact as possible. These are data-driven initiatives in which historical and real-time data analysis can be used to determine a community’s specific needs.
Population health initiatives can only be effective when the entire community comes together, which includes individuals, medical practices, hospitals, rehabilitation centers, community outreach organizations, and more. To accomplish this, population health management involves everything from devising and implementing policies at a facility to coordinating with a variety of organizations in ways that promote better outcomes.
What Defines the Health of a Population?
Population health focuses on the overall health-related outcomes of a specified group of individuals — and a population can be defined in many ways. A population may include an entire nation, such as the United States, or it may include a subset of that nation, such as residents of nursing homes in a single state, prisoners housed in a region of the country, or an ethnic group living in a metropolitan area.
Population health initiatives can focus on numerous issues. In some communities, initiatives may focus solely on improving life expectancy or reducing infant mortality rates. In others, holistic well-being and overall quality of life may be the most pressing concern. No two communities are the same, which means community-based health initiatives are often tailored to that community’s inherent needs.
Issues Impacting Population Health
The factors with the biggest impact on a group of people range from physical to socioeconomic. While proximity to chemical plants or changes in the local climate can alter a community’s overall health, factors related to income inequality, education levels, gender inequality, racial inequity, psychosocial relationships, community participation rates, and even access to clean water can also drastically influence the health of a population.
To improve outcomes at the community level, individuals who choose to work in population health settings must understand how each of these factors influences communities, and in many cases, how they influence one another. For example, a population living in poverty may not be able to access healthy foods or safe environments for exercise, even if they are prevalent throughout the geographical area.
Population Health vs. Public Health
While population health and public health work together to improve communities, some noteworthy differences exist. Public health focuses primarily on the prevention of disease and injury through education, outreach, research, and policy changes. It anticipates issues within communities, then works to prevent those issues.
Population health brings agencies and organizations together in ways that are designed to improve clinical outcomes within a population or community. Through the combination of information and data-driven decision-making, population health seeks to enhance the delivery of health care through better coordination and patient engagement.
10 Key Public Health Services
For the last 25 years, the Centers for Disease Control and Prevention (CDC) has had 10 Essential Public Health Services (EPHS) that have served as a cornerstone in the delivery of exceptional public health. The EPHS seeks to overcome barriers that have led to inequality of care, including poverty and discrimination. These essential services also address the disparities faced in rural health care when compared to its urban counterpart.
1. Monitoring Communities
The first essential public health service involves assessing and monitoring a specific group or population to collect data. Current health status, influential factors, the needs of the community, and the assets available to that community are considered vital data for proper population health management.
2. Diagnosing the Problems
The second essential service is the diagnosis of various health problems that affect a specific population. This involves anticipating and mitigating threats, monitoring issues in real time, identifying patterns, and analyzing inputs to determine the root cause of the issues affecting the community.
3. Educating and Communicating
A major part of managing public health effectively involves communicating with the intended population. These services may involve creating health information that the community can access and understand, choosing and using appropriate channels, utilizing risk reduction techniques, and encouraging two-way communication between healthcare providers and individuals in the community.
4. Mobilizing Groups and Organizations
Mobilizing is all about fostering partnerships between people and organizations that can ultimately improve public health. This may include facilitating the growth of groups and coalitions, encouraging community engagement, and finding new ways to support existing partnerships throughout the community.
5. Developing Policies
Healthcare administrators are crucial in the development and implementation of plans, policies, and even laws that can impact the health of entire populations. This may involve examining the efficacy of existing policies and ensuring those policies are nondiscriminatory, but it also includes working in partnerships to change or introduce policies.
6. Enforcing Policies and Laws
Many communities are governed by laws and policies designed to protect their health. One of the key public health services focuses on enforcing the existing laws and policies, ensuring that these laws are equitable across communities, monitoring the quality of care being delivered in local facilities, and requiring licensure or other credentials for the community’s healthcare workforce.
7. Connecting People with Services
Those who work in population health management must ensure that the systems at work in their communities are both accessible and equitable. This may involve linking at-risk members of the community with holistic services, ensuring those services are cost-effective, and actively seeking and removing the barriers that the community may face when attempting to find care.
8. Creating a Quality Workforce
Developing a quality workforce within a local area is crucial to the overall provision of care. This involves ensuring a wide range of training and education programs are available to healthcare professionals, developing an appropriately-sized workforce, considering the various cultural and linguistic needs of the community, and fostering a love of learning and leadership as it relates to public and individual health.
9. Evaluating Current Programs
Evaluating the strategies employed to improve public health is an ongoing task. It involves continued research regarding new technologies, linking that research with current community practices, and using data to drive decisions that impact the community. Community education programs must change and evolve to continue to improve outcomes.
10. Researching and Innovating
Improvements in health care call for innovation in public health management. Often, public health professionals must continue to reallocate resources, develop and deploy outreach programs, expand information technology (IT) services in hospitals and other facilities, and build a culture of transparency and accountability throughout the community — including individuals, healthcare providers, and organizations.
The Impact of Population Health Management
While the primary goal of managing population health is improving clinical health outcomes at individual and community levels, more specific goals can be broken down into three simple concepts: improving preventative health to reduce health hazards, managing chronic disease to improve overall quality of life, and reducing costs for patients and facilities alike.
Preventative Health Care
Health care that improves outcomes across populations must be preemptive and proactive. Most communities are home to clinics and hospitals that treat patients who are suffering from heart disease or diabetes, but fewer may provide affordable or free smoking cessation workshops, nutrition counseling, and blood sugar screening. These preventative measures require an upfront financial investment, but in the long run, they are vital for improving patient outcomes because they prevent some of the most prevalent conditions.
When communities offer very basic screenings and tests, including blood pressure, diabetes, and cholesterol tests for free or at reduced rates, they are better able to determine which populations are at risk for specific conditions. This facilitates efficient and data-driven provision of care, improves patient and community vulnerability, and reduces the prevalence of serious diseases among communities.
The Office of Disease Prevention and Health Promotion’s Healthy People 2030 initiative is an example of how clear, data-driven objectives can improve health and well-being at the national level. It shows how improving preventative care improves health across a wide range of populations.
Chronic Disease Management
Chronic disease is the No. 1 cause of disability and death in the United States. Per data from the CDC, chronic and mental health conditions account for about 90 percent of the nation’s $4.1 billion in annual healthcare spending. Not only is managing chronic disease effectively one of the best ways to improve clinical outcomes and quality of life across communities, but it is also essential for reducing costs at the individual and community levels.
The management of chronic disease involves identifying those who are at risk, gathering and analyzing data about those people, creating action plans that can reduce risk, and coaching communities in ways that facilitate healthier choices. This may include avoiding the development of chronic disease through no-cost programs focused on smoking cessation, nutrition, and exercise or even expanding existing chronic disease management programs into clinics in at-risk areas.
The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) is a branch of the CDC that focuses on managing chronic disease. Since 1999, the group’s REACH program, which stands for Racial and Ethnic Approaches to Community Health, has addressed countless health issues among minority groups. REACH funds local organizations, schools, county health departments, tribal organizations, and state governments to improve health outcomes within their communities.
Healthcare Cost Reduction
When communities are healthier, they spend less on health care throughout their lifetimes. Preventative health care and chronic disease management are at the forefront of managing the health of a population because they reduce costs at both the individual and the community levels.
Funds that are typically set aside by the state to cover essential health care for low-income populations can instead be reallocated toward even further preventative medicine, community education, or even technology that improves the provision of care for all.
Careers in Population Health Management: Salaries and Descriptions
According to the U.S. Bureau of Labor Statistics (BLS), the demand for healthcare professionals — including administrators — is expected to grow around 13 percent between 2021 and 2031. Healthcare administrators across a multitude of roles are critical for effective population health management. From hospital administrators and CEOs to chief nursing officers and informatics managers, each of these career options has its own unique role in improving public health.
Medical and Health Services Managers
Medical and health services managers, including facility administrators, are responsible for coordinating the activities of the various departments within the facility. They are directly responsible for improving the quality and efficiency of the services provided, they hire and train other staff members, and they are often directly responsible for budgeting, as well.
Because they have so many responsibilities, medical and health services managers are often on the front lines of public health. They determine the breadth and scope of preventative health initiatives in their facilities, and they can choose to fund or cut chronic disease management programs, as well.
In terms of population health management salary, medical and health services managers earned about $101,340 per year as of May 2021, according to data from the BLS. Those working in hospitals earned the highest average salary of about $119,450 per year, while those managing nursing homes and other residential facilities earned the lowest annual salaries of about $83,550 per year, according to the BLS.
Chief Nursing Officer
A chief nursing officer (CNO) may also be called a chief nursing executive (CNE). The CNO generally reports to the chief executive officer (CEO) of a hospital or facility and serves a wide range of supervisory and administrative roles.
The CNO is a valuable asset in terms of public health because they oversee the services delivered by every nurse in the facility. Additional roles may include developing best practices and standards of care in nursing, creating and adhering to budgets for the nursing department, and ensuring the department adheres to regulations. Often, the CNO can play a role in developing policies, which is an important part of public health initiatives.
Chief executive officers earned an average annual salary of $213,020 across all industries as of May 2021, according to the BLS. Per data from Payscale, chief nursing officers earned roughly $138,600 per year as of March 2023. Those salaries may include bonuses and profit-sharing income.
Clinical Informatics Manager
Although informatics is a branch of information technology (IT), informatics managers play vital roles in public health at the administrative level. Clinical informatics managers bridge the gap between an IT department and the rest of a healthcare facility. They are primarily responsible for implementing the systems and processes used to collect, store, transfer, and analyze patient data.
Clinical informatics managers use patient data for multiple reasons, including healthcare service delivery, patient and insurance billing, and in some cases, public health initiatives. Often, clinical informatics managers are charged with collecting and analyzing data in ways that can highlight public health concerns.
The BLS reports that the average annual salary for computer and information systems managers was about $159,010 per year as of May 2021. Payscale reports that the average annual salary specific to clinical informatics managers was about $101,970 a year as of February 2023.
Do Your Part to Improve Community Health
Public health management is vital for improving wellness and health at the community and individual levels. Through actionable, data-driven insights, increases in preventative medicine, and access to chronic disease management programs, communities can drastically reduce their healthcare spending.
If you’re ready to do your part to improve your community’s health, an advanced education, such as Tulane University’s Online Master of Health Administration degree is a great place to start. A master’s degree in health administration degree can prepare you for a career as a CNO, medical and health services manager, clinical infographics specialist, or other administrative roles vital to the success of population health initiatives.