This document outlines a framework for population health management. It discusses fundamentals of population health including individual behavior, community health outcomes, and managing population health. It describes benefits of population health management like prevention and chronic disease management. Critical access hospitals can play a role as conveners by collaborating with local health departments and EMS providers. They can assist with developing population health plans and focus community engagement on key local health issues. The document provides templates for community engagement plans and implementation timelines.

1. 1
Designing a Framework for
Population Health Management
Susan L. Triggs, PhD, MPH, RN
VRHA Annual Conference
December 11, 2014

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OVERVIEW
•Fundamentals of Population Health
•Individual Behavior
•Community Health Outcomes
•Managing the Population’s Health
•Pros and Cons
•Moving the Status Quo Needle
•Sharing Ideas – Marketing
•Engaging People
•State Rural Health Plan

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Fundamentals of Population Health
What
is it?
Relevance to
Relationships
Engagement Empowerment

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INDIVIDUAL BEHAVIOR
Capacity
Capital
Networking
Ecology

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COMMUNITY HEALTH OUTCOMES
• Determinants of Health
• Sick Care
• Preventive Care
• Resource Availability

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POPULATION HEALTH MANAGEMENT
(PHM)
Population health: “The health outcomes of a
group of individuals, including the distribution
of such outcomes within the group.” (Institute
of Health Technology Transformation)

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POPULATION HEALTH MANAGEMENT
(PHM)
• Success Factors
– Collaboration
– Planning
– Community Engagement
• Workforce/Culture
• Economic Development
– Data Collection, Management, and Analysis
• Resources available
• External partners with needed resources
– Outcomes and Impact
(Institute of Health Technology Transformation)

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PHM BENEFITS
• Prevention and chronic disease management
• Health outcomes problems resolved by pooling
resources
• Sharing the weight of PHM among all stakeholder
sectors
• Proactive vs reactive engagement

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MOVING THE NEEDLE
• Self Interest to Shared Agenda
– Community Needs Assessments and Health Needs
Assessments
– Strategic Plans
– Community Action Plans
– Coalitions/Tasks Forces/Consortiums, etc.
– Community Advisory Boards
• Community-Based Participatory
Approaches

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SHARING IDEAS - MARKETING
• Speaking stakeholder language
– Business Systems Thinking
– Youth relevance: How I am affected now
– Seniors: Relevance to aging
– Mid-Lifers: Juggling multiple priorities
– Community at Large: Easy, popular, and fun

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MARKETING
Decision
Point
Product
Place
Price
Promotion

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ENGAGING PEOPLE
TO GET THE JOB DONE
COMMUNITY
Experience
Problem
Solution
Resources
Health
Outcomes

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Some Community
Involvement
Communication flows
from one to the other, to
inform
Provides community with
information.
Entities coexist.
Outcomes: Optimally,
establishes
communication channels
and channels for
outreach.
Outreach
More Community
Involvement
Communication flows to
the community and then
back, answer seeking
Gets information or feed-
back from the community.
Entities share
information. Outcomes:
Develops connections.
Better Community
Involvement
Communication flows both
ways, participatory form of
communication
Involves more participa-
tion with community on
issues.
Entities cooperate with
each other.
Outcomes: Visibility of
partnership established
with increased coopera-
tion.
Community Involvement
Communication flow is
bidirectional
Forms partnerships with
community on each
aspect of project from
development to solution.
Entities form bidirectional
communication channels.
Outcomes: Partnership
building, trust building.
Strong Bidirectional
Relationship
Final decision making is
at community level.
Entities have formed
strong partnership
structures.
Outcomes: Broader health
outcomes affecting
broader community.
Strong bidirectional trust
built.
Consult Involve Collaborate
Shared
Leadership
NIH Publication No. 11-7782 (2011), Principles of Community Engagement
Principles of Community Engagement

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VIRGINIA’S STATE RURAL HEALTH PLAN
Supporting Rural Health through
Community Engagement and Action

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Virginia’s State Rural Health Plan
Obesity and
associated
behaviors and
diseases
Mental and
behavioral
health
Oral healthCancer
Perinatal issues
Lung disease
Key Health Issues:

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Virginia’s State Rural Health Plan
Health
Outcomes
Healthy
Communities
Access to
Health Care
Individual
Empowerment
Workforce
Development
Advocacy
Objectives

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Goals for Rural
Population Health Management
1) Bring widespread attention to current and
anticipated rural health issues and needs
2) Capture the ideas, commitment, and energy of
rural health stakeholders around the
Commonwealth
3) Motivate participation in enacting the state
rural health plan actions among a wide range of
stakeholders
4) Facilitate community engagement

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Critical Access Hospitals as Conveners
Mini-Grants Scope of Work – Services
• Services the Hospital shall perform:
– Function as a core leader of the Virginia State Rural Health Plan
community engagement
– Collaborate with the Department (VDH), the local health
department, and local EMS providers as the core leadership group
in this effort
– Assist with developing population health management work using
the systems-based approach outlined in “Improving Population
Health: A Guide for Critical Access Hospitals”
– Focus community engagement around key health issues identified
in the Hospital’s Community Health Needs Assessment

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23
Key Health Issue(s) Health Outcomes Strategy(ies) Healthy Communities Strategy(ies)
Access to Health Care Strategy(ies) IndividualEmpowerment Strategy(ies) Workforce Development Strategy(ies)
Advocacy Strategy(ies) Hospital Mission/Vision Strategic Planning Population Health Approaches
Partners/Stakeholders Activity(ies) Activity Description
ServiceArea Demographic Data
COMMUNITY ENGAGEMENT PLAN (Template)

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Critical Access Hospitals as Conveners
Mini-Grants Scope of Work – Deliverables:
• Community Engagement Plan: Draft Outline
• Projected Start Date
• Draft Implementation Plan and timeline
estimation

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Critical Access Hospitals as Conveners
• Virginia Rural Health Advisory Board (VRHAB)
– Mission:
• To promote and support the health of Virginia’s rural
communities by advising in the implementation of
Virginia’s State Rural Health Plan.
– Vision:
• Healthy people in healthy rural communities

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Critical Access Hospitals as Conveners
• Community Engagement Plans
-- 5 of 7 CAHs signed a Memorandum of Agreement
-- Going forward
 VRHAB will review, evaluate, provide
recommendations
 CAHs will receive input from VRHAB
 Yearly progress reporting

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CONTACT INFORMATION
Susan L. Triggs, PhD, MPH, RN
Rural Health Program Specialist
susan.triggs@vdh.virginia.gov
804-864-7429

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QUESTIONS