Dean Holzemer

The Dean’s Desk | Thoughts from Rutgers Nursing Leadership

Thoughts on Population Health

Tuesday, September 26, 2017

William L. Holzemer, RN, PhD, FAAN
Rutgers University School of Nursing

The concept of “Population Health” has become an organizing framework for nursing.  It defines how folks think about outcomes when discussing the work of Advanced Practice Nurses (APNs) and it is challenging undergraduate nursing education to move away from the traditional developmental framework to one of aggregated health needs, interventions, and outcomes.   
Population Health has a rich history in nursing, from Nightingale to Barton, and may be the beginning of a movement away from an illness model of care to patient-family-community centered care.  It is an approach that utilizes epidemiology extensively to define aggregated health conditions (e.g. people living with diabetes) and often sets biomarker or medical outcome goals such as control of A1c.  Successful outcomes result from aggregated changes over time, more than the traditional focus on an individual patient/client.

Population Health differs markedly from fully community-based participatory research, where the community struggles to identify areas of need and health care workers are somewhat obliged to address the community-identified needs.  Often, this model of problem identification aligns directly with a biomedical model, but sometimes not.   A community may wish for safer streets so they can walk after work, rather than access to medication for their diabetes.  Population Health may or may not adopt a community-based participatory approach.

Population Health is also very different from the World Health Organization’s long-abandoned slogan, “Health for All by the Year 2000.” There are components of  “Health for All “ that link well to the discussion of Population Health, but it had a greater priority on understanding  inter-sectorial linkage (sanitation, water supply, health workers, schools) etc. than does Population Health.  The WHO’s Alma-Alta Declaration in 1978 was really a statement of health as a right, not a privilege, and one that is impacted by social, environmental, and individual determinants of health.  Population Health appears to be silent on the issue of health care as a right.

Adoption of the concept of Population Health stems in part from the extremely difficult challenge of controlling the costs of health care, particularly in the United States.  Directing interventions that have the greatest potential to meet the needs of groups of individuals may increase access, improve health outcomes, and assist in controlling costs.  Adopters of Population Health are challenged to understand the goals of their work to be clear about where controlling health care costs ranks on their list of purported outcomes.  There is no doubt that controlling costs must be on the list!

Population Health requires expertise in data management, understanding concepts such as variance, and ability to bench mark outcomes over time.  It challenges the difference between statistical significance and clinical significance when examining aggregated outcomes.  

It also is challenged by determining the cost of care to the insurance provider, health care worker, patient, and/or the family.  “Big data” collected from electronic health records is creating new opportunities to diagnose problems, implement interventions, and monitor Population Health outcomes. Academic nursing programs are challenged to provide the training required for these new analytical models.

Perhaps most important of all, Population Health is silent on one of the greatest ethical questions of our time:  “Do individuals have the right to access affordable, quality health care?”  “What role should our government play in the delivery of health care? The dialogue about Population Health is challenged to include the discussion of access to and payment for health care.  Population Health offers new ways to think about the delivery and quality of care, but not the fundamental issues of human rights.


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