Population Health Improvement at HealtheConnections

Wednesday, October 26, 2016

Many healthcare providers think of HealtheConnections as the RHIO (Regional Health Information Organization) for the region, and associate the organization with the specific services that help them access their patients’ records. In fact, HealtheConnections takes part in a broader set of activities in service of the Triple Aim’s better care, better health and lower healthcare costs.

Doctor using laptop

HealtheConnections’ Population Health Improvement team, which began work in February 2015, engages with a large and diverse network of stakeholders to improve the health of Central New Yorkers, using a variety of strategies, from promoting best practices for clinical prevention to community-wide prevention that benefits the total population. This work is supported by several state and national funders.

Definition of Population Health

The term “population health” is used to describe the health of a specific group of people. The group could be defined in many different ways: by region, using demographic factors or the patients served by a particular healthcare provider. In our current era of health system transformation, “population health” frequently refers to the management of subpopulations with complex needs. HealtheConnections uses the term to refer to the health of the total population of the geographic community of Central New York.

The Population Health Approach

It is imperative to consider the overall context of the community in which health care is being provided in order to increase the effectiveness of clinical interventions. While clinical care accounts for 10–20 percent of overall health outcomes, according to the New York Academy of Medicine, it is the social determinants of health — such as adequate employment opportunities, quality housing and access to transportation — that have a proportionally larger influence on a community’s health.

The pyramid pictured below, adapted from the Centers for Disease Control and Prevention, summarizes the potential impact of different types of interventions on the health of a population.

HealtheConnections’ work concentrates on several levels of this pyramid, using strategies that fortify the role of healthcare providers serving individual patients, while also impacting the work places, neighborhoods and community settings where these individuals spend their days.

Our success in working at different levels of the pyramid and in diverse communities across the region is strengthened by our relationship with a steering committee composed of a representative organization from each of seven Central New York counties. These partners include Cayuga Community Health Network, Seven Valleys Health Coalition of Cortland County, Herkimer County HealthNet, Madison County Rural Health Council, CNY Health Home Inc. of Oneida County, Onondaga County Health Department and Oswego County Opportunities.

Examples of HealtheConnections’ Population Health Improvement Efforts

Our population health work, carried out in collaboration with our steering committee and other partners, includes:

  • Engaging a variety of health and human services stakeholders, as well as nontraditional stakeholders such as transportation, business and payers
  • Maintaining a website (HealtheCNY.org) that provides access to data, evidence-based practices, and local resources for health and human service professionals
  • Promoting evidence-based improvements to institutional policies and community spaces, to enable people to be physically active, make healthy food choices and prevent chronic disease
  • Using a practice facilitation approach to share best practices with providers on the recognition and monitoring of prediabetes and hypertension
  • Enhancing the chronic disease prevention and management program infrastructure

For more information on HealtheConnections’ Population Health Improvement efforts, contact Alicia Schaumberg, at aschaumberg@healtheconnections.org.