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ROCC Star Perspective | June 2016

The Importance of Community and Vitality Promotion to Population Health

Matthew F. Hudson, Ph.D,  M.P.H.
Cancer Care Delivery Research Director
Comparative Effectiveness Research Director
Greenville Health System (Greenville, S.C.)

Approximately 60% of variation in hospital readmission is explained by county-level factors [1, 2].  This suggests that the myriad research strategies undertaken to evaluate and improve clinical practice[3] may fail to optimally impact the social, political, and environmental context that portends peoples’ need for care[4].  Clinical practice and the general public would benefit from a more expansive consideration of health determinants, beyond the traditional confines of clinical departments and hospitals.  This perspective is not novel, as seminal work broadened the context for how we conceptualize health mediators outside traditional care systems [5].  Challenges and opportunities presented in the Affordable Care Act heighten advocacy for a population health perspective.  I encourage us to critically consider what motivates this term/perspective, and ponder the implications.

Previous work observed that the term “population health” retained little consensus on a precise definition[6, 7].  In fact, Nobel and colleagues[8] solicited Accountable Care Organization (ACO) and public health leaders, on their distinctions between the terms: “population health”, ”public health”, and “community health”.    Nobel et al. found that ACO leaders more frequently defined population health according to a defined group of patients, as opposed to patients living in a geographic area.  Public health agency leaders were more likely to consider the three terms the same or similar.  Nobel et al. argue for enhanced definition clarity and consistency; they future caution practitioners that “[u]sing the phrase ‘population health’ to refer to a defined group of patients is misleading, though well intentioned.  It could divert attention from the social determinants of health within geographic areas and to the resources and measures needed to improve geographical population health.  This risk is significant, given the underfunding of public health agencies (p.5)”.

To guide our framing of population health, consider Minar and Greer’s definition of “community”.  They assert the term “expresses our vague yearnings for a commonality of desire, a communion with those around us, an extension of the bonds of kin and friend to all those who share a common fate with us”[9].  If we apply this perspective to population health, three elements emerge.  First, we cease to define people by their clinical condition, or their success in accessing clinical care (i.e., “patient” status).  This is not inconsequential, as it avoids overprioritizing a biomedical paradigm[10] and additionally marginalizing populations traditionally challenged to access healthcare[11].  Second, we temper, without obviating, the causal inference that environment begets health.  It is possible individuals select (or are selected into) their neighborhood based on their health or predisposition to certain behavior  (e.g., healthier people select or create neighborhoods with walking paths and athletic facilities) [12].  Most important, what emerges when informed by Minar and Greer’s perspective, is population health as an intimate, shared experience; population health is an opportunity for fellowship/“communion” with the individuals we purport to serve.  In this communion, we acknowledge a “sharing of a common fate”-we engage the relationship understanding that one person’s health is my health.  Thus, when community, as defined above, undergirds population health, care systems will cease contemplating ways of “managing” populations (i.e., doing “to” people, patients, or groups).  Instead, care systems will innovate relationships (doing “with” people, patients, or groups) that advance our common, mutually-beneficial vocation of vitality promotion (i.e. promoting the capacity of neighbors to not only live, but prosper).  In this sense, population health is a solemn service, not a “strategy”. The vitality promotion spirit is the essential antecedent to the population health definition.

Macro-level shifts show promise for integrating this vitality promotion spirit into the health care workforce consciousness.  For example, the National Cancer Institute (NCI) is advancing Cancer Care Delivery Research (CCDR)-a multidisciplinary investigation of the relationship between social factors, financing systems, organizational structures and processes, health technologies, provider and patient behaviors, relative to cancer care access quality and cost; CCDR ultimately considers this relationship’s impact on cancer patients’ and survivors’ health and well-being[13, 14].  CCDR complements NCI’s historical emphasis on the biomedical paradigm undergirding the randomized, controlled, clinical trial.  CCDR assumes pragmatic research approaches elucidating and promoting optimal care in “real world” clinical practice[15, 16].   Health service research innovation, alone, may not affirm CCDR’s relevance. Rather, it is NCI’s aspiration to hardwire the consideration of “social forces” into oncology service scholarship.  Thus, NCI affirms their acknowledgement of, and investment in addressing, clinically-remote factors mediating oncology service impact, prior and subsequent to clinical care.  Addressing CCDR’s charge will mandate increased engagement with community-based care institutions, and the communities the care institutions serve.

While macro-level calibrations are essential to culture change, care systems are challenged to operationalize and implement changes at the “grass-root” level. Authentic partnering with stakeholder groups may advance vitality promotion.  However, this approach may mandate care systems relinquish their assumed position as the prime arbiter of, and lynchpin to, health and wellness .  Public Health practitioners, generically, are more familiar with this approach. Early and sustained efforts in community-based participatory research[17, 18]provide some experience in partnering with non-clinical community members.  Health care is adopting these tenets, as evidenced by the Patient Centered Outcomes Research Institute (PCORI)[19, 20].  This organization demonstrates clinical practitioners’ increasing amenability to co-partnering with lay persons to identify research topics, generate hypotheses, and co-design studies [21].  Further, care organizations are increasingly availing themselves of legislative and enforcement offices to optimize the impact of pre-existing, health-protective laws [22].  It appears, then, that traditional health care and wellness constituents are willingly adjusting to macro-level shits promoting inclusivity, and appropriate diffusion of responsibility for health and wellness.      

While health care welcomes partners in health promotion and disease prevention, care institutions should consider their communities (geographically defined) readiness and desire for this relationship (and the responsibility it entails). In the same way patients may variably desire involvement in medical decision making[23], communities may ultimately prefer care systems adhere to biomedical paradigms and paternalistic approaches to clinical practice and illness management.  Additionally, resource availability or cohesiveness may variably challenge communities to embrace the population health brand espoused above.  Consequently, traditional health care organizations should view health advocacy efforts on an engagement continuum; traditional care organizations should provide their communities that which their communities solicit, and continually propose collective efforts to advance shared aspirations.

The discussion above argues practice challenges and projected policy mandates provide an opportunity to consider motivations for population health.  Examining assumptions undergirding “population health” may clarify challenges and opportunities to achieve wellness in patient and non-patient groups.  Advancing the concept of community and investment in vitality promotion may ensure robust care impact, evidenced by reduced need for hospital use, and judicious use, when medical care is necessary.    



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