Population, Community, and Public Health Management: Cases and Concepts, Second Edition

By Simone R. Singh, Jason S. Turner and Connie J. Evashwick

To provide optimal care for their patients, healthcare leaders must consider the broader context in which care is delivered. Population, Community, and Public Health Management explains how to improve care for patients and the broader community by applying management concepts beyond the walls of an individual institution.

This extensively revised second edition has evolved from a casebook into a core textbook. Eight expanded overview chapters give students the definitions, frameworks, and primary concepts they need to analyze the case studies. Didactic chapters on population, community, and public health examine the differences and similarities between these fields from a management viewpoint.

The book features 16 real-world cases that present multi-faceted, complex management dilemmas in settings that extend beyond hospitals and doctors' offices. Existing themes of value-based financing and population health management are pursued in updated cases focused on veterans health, services for seniors, and more. Seven cases new to this edition explore current topics such as integrating public health and healthcare delivery and providing healthcare to immigrant children via schools.

• Language: English
• Publisher: AUPHA/HAP Book
• Release date: Oct 15, 2023
• ISBN: 9781640554023

Book preview

Front Cover: Population, Community, and Public Health Management, Second Edition, Cases and Concepts, Connie J. Evashwick, Jason S. Turner, and Simone R. Singh, Editors

Population, Community, and

Public Health Management

HAP/AUPHA Editorial Board for Graduate Studies

Ning Lu, PhD, Chair

Governors State University

Robert I. Bonar, DHA

George Washington University

Kim C. Byas, Sr., PhD, FACHE

Union Institute & University

P. Shannon Elswick, FACHE

University of Central Florida

Stephen F. Gambescia, PhD

Drexel University

Renady Hightower, PhD

University of Detroit Mercy

Cheryl J. Holden, DHS

University of Arkansas—Fort Smith

Sandra S. Murdock, DrPH, FACHE

Texas Woman’s University

Jonas Nguh, PhD, RN, FACHE

Walden University

Martha C. Riddell, DrPH

University of Kentucky

Carmen Teresa Saunders-Russell, EdD

California State University—Northridge

Karen M. Volmar, JD, FACHE

University of North Carolina at Chapel Hill

Asa B. Wilson, PhD

Southeast Missouri State University

Population, Community, and Public Health Management, Cases and Concepts, Second Edition, Connie J. Evashwick, Jason S. Turner, and Simone R. Singh

Your board, staff, or clients may also benefit from this book’s insight. For information on quantity discounts, contact the Health Administration Press Marketing Manager at [phone].

This publication is intended to provide accurate and authoritative information in regard to the subject matter covered. It is sold, or otherwise provided, with the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The statements and opinions contained in this book are strictly those of the authors and do not represent the official positions of the American College of Healthcare Executives or the Foundation of the American College of Healthcare Executives.

Copyright © 2023 by the Foundation of the American College of Healthcare Executives. Printed in the United States of America. All rights reserved. This book or parts thereof may not be reproduced in any form without written permission of the publisher.

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Library of Congress Cataloging-in-Publication Data

Names: Evashwick, Connie, editor. | Turner, Jason S., editor. | Singh, Simone, editor. | Health Administration Press, publisher. | Association of University Programs in Health Administration, issuing body.

Title: Population, community and public health management : cases and concepts / [edited by] Connie J. Evashwick, Jason S. Turner, Simone Singh.

Other titles: Case studies in population and community health management

Description: Second edition. | Chicago, Illinois : Health Administration Press ; Washington, DC : Association of University Programs in Health Administration, 2023. | Preceded by Case studies in population and community health management / Connie J. Evashwick, Jason S. Turner, editors. 2020. | Includes bibliographical references. | Summary: To provide optimal care for their patients, healthcare leaders must consider the broader context in which care is delivered. Population, Community, and Public Health Management explains how to improve care for all patients by applying management concepts beyond the walls of an individual institution. The significance of social determinants of health and issues related to health disparities and health equity are highlighted in this edition. These themes are woven throughout the text so students see how these concepts apply to real-world patient care situations. Population, Community, and Public Health Management will broaden future leaders’ perspectives, and teach them how to apply healthcare management principles across institutional boundaries to the benefit of their patients and their communities– Provided by publisher.

Identifiers: LCCN 2023015456 | ISBN 9781640554009 (trade paperback) | ISBN 9781640554016 (ebook) | ISBN 9781640554023 (epub)

Subjects: MESH: Community Health Planning | Population Health Management | Community Health Services– organization & administration | Needs Assessment | Organizational Case Studies | United States

Classification: LCC RA790.55 | NLM WA 546 AA1 | DDC 362.2/2–dc23/eng/20230721

LC record available at https://lccn.loc.gov/2023015456

ISBN: 978-1-64055-400-9

The paper used in this publication meets the minimum requirements of American National Standard for Information Sciences—Permanence of Paper for Printed Library Materials, ANSI Z39.48-1984. ♾™

Manuscript editor: Kevin McLenithan; Cover designer: James Slate; Layout: Integra

Found an error or a typo? We want to know! Please e-mail it to [e-mail], mentioning the book’s title and putting Book Error in the subject line.

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To Maya, Oliver, and Gabriel.

SS

To my wife and children, who consistently demonstrate patience with and support of me.

JT

For my son, a newly minted physician, with the hope that his generation of healthcare professionals will excel at collaborating with the many organizations that collectively care for the patients and families in the community.

CE

BRIEF CONTENTS

Preface to the Second Edition

Acknowledgments

  Part I    Introduction

Chapter 1.    Introduction and Definitions

Connie J. Evashwick

Chapter 2.    The Societal Context for Health and Healthcare

Darren Liu and Betty Burston

Chapter 3.    Theories Related to Health Behavior

Minal R. Patel

Chapter 4.    Population Health Data and Measures

Rosemary Caron

  Part II    Public Health

Chapter 5.    Public Health in the United States

Connie Evashwick and Michael Rubyan

Case 1.    Coordinating a Community Response

Michael Rubyan and Joneigh Khaldun

Case 2.    Collective Action for Collective Impact

Carleen Stoskopf, Wilma J. Wooten, and Nick Macchione

Case 3.    Building Community Partnerships

James A. Rice

Case 4.    Responding to an Environmental Emergency

Marissa Venn

Case 5.    Mobilizing School Health to Meet Global Needs

Ellen Evashwick

  Part III    Community Health

Chapter 6.    Introduction to Community Health

Connie Evashwick and Courtney Rice

Chapter 7.    Overview of Community Benefit

Simone R. Singh, Jason S. Turner, and Connie Evashwick

Case 6.    Characterizing a Community

Connie Evashwick

Case 7.    Mapping Community Assets

Connie Evashwick and Jillian Warriner

Case 8.    Balancing Ethics and Finances in Making Decisions

Michael Rozier

Case 9.    Addressing Social Needs of Patients, Caregivers, and the Hospital

Melanie Kitagawa

Case 10.  Meeting Community Health Needs: From Assessment to Implementation Strategy

Cory E. Cronin, Berkeley Franz, Autumn Glover, Mary Ann G. Abiado, and Tara Gilts

  Part IV    Population Health

Chapter 8.    Population Health Primer

Jason S. Turner

Case 11.  Managing Risk for Population Health

Jason S. Turner

Case 12.  Coordinating Care and Payment for People with Mobility Limitations

Allyson G. Hall, Reena Joseph Kelly, James H. Rimmer, Charles L. Angel Jr., and Jamie Wade

Case 13.  Managing Cost and Quality of Care for Older Veteran Populations

Orna Intrator, Catherine Kelso, and Scotte Hartronft

Case 14.  Planning the Future of a Continuing Care Retirement Community

Robert E. Burke

Case 15.  Addressing Cancer Disparities in Iowa

Tami Swenson

Case 16.  Applying Telehealth to Advance Service at Federally Qualified Health Centers

Rakesh Patel and Kelly Sevcik

Glossary

Index

About the Editors

About the Contributors

DETAILED CONTENTS

Preface to the Second Edition

Acknowledgments

  Part I    Introduction

Chapter 1.    Introduction and Definitions

Connie J. Evashwick

Defining Population Health, Community Health, and Public Health

Population Health

Community Health

Public Health

Overlapping Functions

Summary and Conclusions

References

Chapter 2.    The Societal Context for Health and Healthcare

Darren Liu and Betty Burston

The Societal Context

Social Determinants of Health

Health Disparities

Cultural Awareness

Health Literacy

Relevance to Population Health

Summary and Conclusions

References

Chapter 3.    Theories Related to Health Behavior

Minal R. Patel

The Health Belief Model

The Theory of Reasoned Action/Planned Behavior and Integrated Behavioral Model

Integrated Behavioral Model

Stage Models

Social Cognitive Theory

Diffusion of Innovation

Product Life Cycle

Summary and Conclusions

References

Chapter 4.    Population Health Data and Measures

Rosemary Caron

Uses for Population Health Data

Assessing the Health of a Community

Health Measures

Sources of Public Health and Healthcare Data

Population Health

Summary and Conclusions

References

  Part II    Public Health

Chapter 5.    Public Health in the United States

Connie Evashwick and Michael Rubyan

The Essential Public Health Services

Other Frameworks for Organizing Public Health Services

A Brief History of Public Health

Organization and Structure of Government Public Health in the United States

Funding for Public Health

The Public Health Workforce

National Standards and Public Health Accreditation

Public Health in the Private Sector

Public Health Tools and Data

Global Public Health

Organizational Resources for Public Health

Summary and Conclusions

References

Case 1.    Coordinating a Community Response

Michael Rubyan and Joneigh Khaldun

Management Challenge

Background of ABE

Jasman County

Aerial Treatments

Plan of Action

Next Steps

Questions

Resources

Reference

Case 2.    Collective Action for Collective Impact

Carleen Stoskopf, Wilma J. Wooten, and Nick Macchione

Management Challenge

Live Well San Diego Background

Community Dashboard

Management Dilemma

Next Steps

Questions

Resources

References

Case 3.    Building Community Partnerships

James A. Rice

Management Challenge

Background

The Cancer Crisis

Countryside Public Health and Its Leadership Agencies

Countryside’s Efforts to Mobilize Community Health Partners

Building Collaborative Governance and Joint Partner Planning

Questions

Resources

References

Case 4.    Responding to an Environmental Emergency

Marissa Venn

Management Challenge

Background

What Happens When There Is a Hazardous Chemical Release in a Community?

Identifying Health Effects of Chemical Hazards

Occupational Exposure Limits

Hospital Care Following the Accident

Communicating with the Public During a Crisis

Coordination with Agencies to Improve Health Outcomes During and After an Emergency

Population Health and Public Health Tracking

Epilogue

A Note About Environmental Justice and Health Equity

Questions

Resources

References

Case 5.    Mobilizing School Health to Meet Global Needs

Ellen Evashwick

Management Challenge

School Health Programs

Immigrant Health Issues

Sandrene’s To Do List

Required School Health Services

Implementation Plan

Questions

Resources

  Part III    Community Health

Chapter 6.    Introduction to Community Health

Connie Evashwick and Courtney Rice

Overarching Framework

Define the Community

Aggregate Resident Characteristics

Organizations and Community Health Systems

CHNAs and CHIPs

Ecological Model Outer Spheres

Summary and Conclusions

Resources

References

Chapter 7.    Overview of Community Benefit

Simone R. Singh, Jason S. Turner, and Connie Evashwick

Definition

History

Current Trends and Future Outlook on Hospital Community Benefit

Policy Recommendations

Summary and Conclusions

References

Case 6.    Characterizing a Community

Connie Evashwick

Management Challenge

Background

Questions

Resources

Case 7.    Mapping Community Assets

Connie Evashwick and Jillian Warriner

Management Challenge

Background

Needs of Seniors

Continuum of Care

Asset Mapping

Caregivers and Workforce

Financial Arrangements

Questions

Resources

References

Case 8.    Balancing Ethics and Finances in Making Decisions

Michael Rozier

Management Challenge

Background

Greenville Hospital and Its Mission

An Intervention for Severe Childhood Asthma

Select Ethical Principles

Avoiding the Application of Medical Ethics to Community and Population Health

Key Points About Ethical Discernment

Moving Forward

Questions

Resources

Reference

Case 9.    Addressing Social Needs of Patients, Caregivers, and the Hospital

Melanie Kitagawa

Management Challenge

Background

Community Children’s Hospital

Improving Outcomes for Children with a New Tracheostomy

Pediatric Tracheostomies

Social Needs and Social Determinants of Health in Children with Medical Complexity

The Effect of Social Needs in the CMC-ICU

Research Implications

The Challenge

Questions

Resources

References

Case 10.  Meeting Community Health Needs: From Assessment to Implementation Strategy

Cory E. Cronin, Berkeley Franz, Autumn Glover, Mary Ann G. Abiado, and Tara Gilts

Management Challenge

Background of Needs Assessments

CHNA and IS Requirements

Case Background

Hospital Background

Community Overview

CHNA Report Summary

Implementation Strategy Process

Implementation Strategy Plan

Epilogue

Conclusions

Questions

Resource

References

  Part IV    Population Health

Chapter 8.    Population Health Primer

Jason S. Turner

Population Health Program Development Process

Implementing Change

Population Health Management

Determining Success

The Relationship of Population Health to Value-Based Financing Initiatives

Summary and Conclusions

References

Case 11.  Managing Risk for Population Health

Jason S. Turner

Background

Chicago Community

Drivers of Value-Based Methodologies

Transfer of Risk

Charge to the Executive Leadership Team

Questions

References

Case 12.  Coordinating Care and Payment for People with Mobility Limitations

Allyson G. Hall, Reena Joseph Kelly, James H. Rimmer, Charles L. Angel Jr., and Jamie Wade

Management Challenge

Background: Spinal Cord Injury

The Regional Academic Health System

Community Rehab Foundation

Collaboration

Patient Perspective Excerpts

Task Force Objectives

Questions

Resources

References

Case 13.  Managing Cost and Quality of Care for Older Veteran Populations

Orna Intrator, Catherine Kelso, and Scotte Hartronft

Management Challenge

Background

Strategies

Shifting from a Hospital Focus to a Home-Based Orientation

Jose Lopez and the Clinic in the Southwest

Questions

Resources

References

Case 14.  Planning the Future of a Continuing Care Retirement Community

Robert E. Burke

Management Challenge

Background

CCRC Definition

Evergreen Continuing Care Retirement Community

Demographic Trends

Trends in Senior Services

Trends in Financial Models and Risk Allocation

The Strategic-Plan Consulting Engagement

Strategic Plan Elements

Conclusion and Recommendations

Questions

Resources

Reference

Case 15.  Addressing Cancer Disparities in Iowa

Tami Swenson

Management Challenge

Background

The Iowa Cancer Consortium’s Diversity and Equity Strategic Planning

Management Approach to Evaluation and Revision

Questions

Resources

References

Case 16.  Applying Telehealth to Advance Service at Federally Qualified Health Centers

Rakesh Patel and Kelly Sevcik

Management Challenge

Background

Background of Neighborhood

Telehealth at Neighborhood

The Opportunities and Challenges of Telehealth

Next Step for Telehealth

The Future

Questions

References

Glossary

Index

About the Editors

About the Contributors

PREFACE TO THE SECOND EDITION

The overarching purpose of this book is to apply healthcare management concepts to contemporary healthcare problems of community, public, and population health while maintaining excellence in providing services for individual health. Although this shift in perspective can be challenging, we hope this book will make the change meaningful and rewarding.

Introduction

In the three short years since the first iteration of this book, several disparate drivers have amplified the importance of public, community, and population health to the field of healthcare management (HM) and brought dramatic changes to the landscape of education. This book’s predecessor, Case Studies in Population and Community Health Management, consisted primarily of case studies with minimal background. Pandemic-related challenges to health profession education, nationwide social justice movements, and changes in accrediting requirements led us to recreate the book as a core textbook with background content as well as cases and to reframe the book to emphasize the themes of public health, community health, and population health. A critical underlying premise is that each of these spheres plays out differently from one community to another and thus no single way of managing will be universally appropriate. Understanding the key overarching concepts and developing the ability to apply them locally are therefore essential for a healthcare executive’s success.

The revised case study book has the infrastructure to support an expansion of the content to meet the market demands for knowledge and skills related to public health, for more in-depth management of community health, and for renewed attention to population health. This edition has an introductory section with explanations of foundational content: definitions, frameworks, and data; an overview chapter begins each of the three ensuing sections. The cases encourage students to explore all three subject areas to understand how these fields overlap and how each is distinct from a management perspective. Resources at the end of each chapter and case, as well as in the Instructor’s Guide, send students in directions that might not come up in standard HM coursework.

Using This Book

The case-study approach in this book is based on pedagogical principles applicable to adult learners. The guiding theory is that adults learn more by analyzing problems, finding data, applying management theories, and proposing solutions than by having information dictated to them. The cases in this book present opportunities for healthcare executives and for students of all healthcare disciplines taking management courses to analyze real-world situations, find and apply data, and pose practical approaches to address the issues presented. Challenges and solutions should be supported with data. No single answer is expected. Critical thinking and robust discussion are encouraged.

Competencies and Learning Objectives

The overarching theme of the cases is the application of generic management skills to the healthcare system in the United States. Cases are intended to arm students with practical skills—identified here as competencies—as well as didactic knowledge, or learning objectives.

The learning objectives are broad in scope and might emphasize acquisition of didactic knowledge as a prerequisite or foundation for application. The competencies are drawn from those prioritized by health-profession accrediting agencies, including the Council on Education for Public Health, the Commission on Accreditation of Healthcare Management Education, the Certified Health Education Specialist credentialing body, and the Public Health Institute.

The cases can be distinguished from other forms of healthcare management literature in that they present a healthcare system that extends beyond the walls of a given organization, encompassing service providers and payers, coordinating health and social service agencies in a community, and extending to the social determinants of health. For any given management function (e.g., finance, strategic planning, human resources, quality assurance), students will need to look beyond the traditional focus on hospitals and physicians’ offices to analyze how these functions are performed in other types of organizations.

Cases can be adapted to meet the accreditation requirements, pedagogical frameworks, or syllabus templates applicable to an individual program or institution. The learning objectives identified for each case should be useful regardless of which framework or accreditation body governs a given program. From an applied perspective, good management skills are equally relevant to all disciplines.

Overall, the cases in this book are intended to help students master the breadth of knowledge and skills needed to do the following:

Define and differentiate the terms public health, community health, and population health.

Analyze the health status of a community or population, measure changes in the health status of a community or population over time, and evaluate the effect of specific interventions on the health status of a community or population over time.

Examine social contexts, including upstream factors, the social determinants of health, and concepts drawn from the ecological model of health.

Evaluate the roles of state and local public health departments in influencing and protecting the health status of a community.

Analyze the components of a community’s healthcare system, which includes identifying and characterizing providers, payers, regulators, and other stakeholders.

Apply fundamental management skills to community and population health; such skills span the fields of strategic planning, human resources, information systems, finance, marketing, communications, project management, and others.

Conduct a community health needs assessment and develop a community health improvement plan.

Explain the information systems necessary to monitor and manage the health of a population across settings and over time.

Analyze the business case for a healthcare organization to manage the health of a defined population.

Evaluate the effectiveness of communications techniques designed for public health, community health, and population health.

Explain the role of public policy in public health, community health, and population health.

Evaluate public health, community health, and population health programs from the perspective of identifying effective programs and sustaining them over time.

The cases are grouped into three sections: Public Health, Community Health, and Population Health. Each case is a stand-alone example of a real-world situation, and each requires understanding of a target audience and stakeholders, analysis of the problems, a search for relevant data to inform the issue, critical thinking to identify action options, and decision-making criteria. An evidence-based approach includes projecting SMART objectives—that is, objectives that are specific, measurable, achievable, relevant, and time-bound—and evaluation with measurable targets of success.

Each case is framed by a management challenge. Students are asked to respond to a specific task, drawing from the background information presented. However, many secondary topics are woven into the cases, proffering opportunities for students to pursue additional information about health conditions, target audiences, or management applications. Questions of Fact and Discussion Questions are provided at the end of each case. The latter have no predetermined answers and are intended to spark analysis and exploration.

Timeliness and Ethics

The cases in this book represent both real-world communities and organizations and ones that are fabricated based on the authors’ real experience. All real organizations have given permission to have their information included. We ask for readers’ appreciation for the sensitivity of information, both that which is presented here and that which can be found on the internet or via other sources. Similarly, to emphasize the importance of acting on evidence, we have sought to provide data in both hard and fluid formats. If information has changed, is no longer available, or a community context has evolved, readers can regard such developments as part of real-time management and can modify the case accordingly.

Chapters and Cases

Part I of this book, the Introduction, includes four overview chapters on definitions, societal context, theories of health behavior, and data, respectively. These are not intended to be academic reviews, complete and extensively referenced, but rather overviews of key terms, concepts, and frameworks for those otherwise unfamiliar with the subject matter.

Part II, Public Health, focuses on the public health system of the United States. Chapter 5 describes the infrastructure of US public health. Cases 1 through 3 delve into management issues that occur at local and state levels. Case 4 explores public health management from an environmental health perspective. Case 5 combines elements of school health and global health with public health.

Part III, Community Health, includes an overview of community health in general in chapter 6 and a separate overview of hospital community benefit in chapter 7. Cases 6 and 7 entail analyzing the characteristics of a community. Cases 8, 9, and 10 take different perspectives on how healthcare executives of one institution make management decisions that involve working with organizations and sub-populations in the community.

Part IV, Population Health, begins with an overview of the population health framework in chapter 8. Cases 11 through 16 explore population health for subgroups of various characteristics and varied levels of risk.

The Glossary defines terms used throughout the book.

Despite being positioned in specific sections, all cases contain multiple elements appropriate for analysis of management functions, challenges to explore new terms and data sets, and opportunities to apply management concepts beyond the walls of a given institution to incorporate community and population perspectives.

Instructor Resources

This book’s Instructor Resources include an instructor’s guide and PowerPoint slides.

For the most up-to-date information about this book and its Instructor Resources, go to ache.org/HAP and search for the book’s order code (2490I).

This book’s instructor resources are available to instructors who adopt this book for use in their course. For access information, please email [e-mail].

ACKNOWLEDGMENTS

We would like to thank the many people who urged us to take on the rather daunting task of tackling all three subject areas of population, community, and public health. We are humbled in our efforts to fulfill this task and grateful for the support we have received from so many.

Our deep thanks to all authors who contributed not only written work but also ideas and suggestions. We greatly appreciate their willingness to work with us to reshape and revise their own work to make a more comprehensive, cohesive collection.

Our thanks to our faculty colleagues who helped to refine cases and chapters through thoughtful reading and reasoned critiques: Professors Anne Hewitt, Cory Cronin, Judith Connell, Salma El-Amin, Elizabeth Evashwick, Eddie Hooker, Chuck Mathews, and Courtney Rice. Professor Emeritus Robert Burke deserves recognition for inspiring this book by his vision to include community and public health in the core curriculum for health management executives.

The current and former staff of Health Administration Press provided support and guidance throughout the process. We would like to thank Janet Davis and Jenette McDonald, Michael Cunningham and David Bartholomew, Molly Lowe, and La’Toya Carter. They encouraged us through the first edition and shared our vision to expand the content to create the second iteration as a new textbook, with the recognition that incorporating these subjects is essential to the health management education of the future. Mike Noren, for the first edition, and Kevin McLenithan, for this second edition, were outstanding text editors.

The Association of University Programs in Health Administration (AUPHA) embarked upon a major revision of the Body of Knowledge in 2021. The Work Group on Population, Community, and Public Health created a reference document for the book. The discussions that extended over six months both informed the content and reassured us that we were on target in covering these three distinct but related topics.

Our respective families have all cheered us on and tolerated our absence as we buried our heads in manuscripts and keyboards. We are grateful for their love and acceptance of our passion for this work.

Finally, we would like to acknowledge the value of team effort. Although many of us in healthcare management education teach about teams, we do not often enough have the experience of working with a strong team on a prolonged basis. Our team of three coeditors, with complementary subject expertise and skill sets, was productive but, more importantly, always positive about moving forward.

PART

I

INTRODUCTION

CHAPTER

1

INTRODUCTION AND DEFINITIONS

Connie J. Evashwick

The purpose of this book is to use the analysis of practical cases to educate healthcare leaders about managing the health of populations and communities. Historically, healthcare executives have been taught how to lead and manage within their organizations, with minimal attention to external relationships. However, in the contemporary healthcare landscape—with evolving payment models and growing recognition of the importance of social and cultural determinants of health—this kind of internal orientation is no longer sufficient. The ability to manage beyond the walls of the institution has become essential for the success of any healthcare leader.

Today’s healthcare leaders must understand the communities they serve, the special populations for which they assume risk, and the other organizations along the continuum of care that provide or pay for services. The cases in this book emphasize the application of healthcare management principles and skills across institutional boundaries to manage the health status of a population or a community effectively.

Defining Population Health, Community Health, and Public Health

The concepts of population health, community health, and public health are closely intertwined, as shown in exhibit 1.1. They may overlap, but they are not synonymous. An important task for a healthcare executive is to understand the distinctions between the terms and the implications for effective management.

EXHIBIT 1.1

Population, Community, and Public Health

A Venn diagram showing the interconnection between population, community, and public health. The top circle indicates population health, the left-side circle indicates community health and the right-side circle indicates public health.

Although consensus on these terms’ precise meanings is lacking, this section will propose definitions to be used in analyzing the book’s cases. We offer these definitions with the understanding that good managers will see beyond the verbiage to analyze situations and propose realistic and measurable approaches based on the desired goals and objectives. Regardless of the phrasing, common management principles apply. Exhibit 1.2 highlights characteristics that lead to management differences across the three types of programs. We expand upon the distinctions in the following sections.

EXHIBIT 1.2

Comparison of Popula tion Health, Public Health, and Community Health Programs

A table listing the characteristics of population health, public health, and community health programs.

Population Health

Kindig and Stoddart (2003, 381) define population health as the health outcomes of a group of individuals, including the distribution of such outcomes within the group, and the factors affecting those outcomes. Although a variety of definitions of population health have been put forth, the Kindig and Stoddart definition was adopted by the National Academy of Sciences Roundtable on Population Health Improvement (2019) and is applicable to the cases in this book.

The concept of population health implies both a measurable numerator and a measurable denominator, and it incorporates the principles of intended interventions and the ability to measure changes over time. Populations can be subgroups within communities, can encompass multiple communities, or can cut across community lines.

Population health management (PHM) is a more explicit term that describes active interventions to control the health status or healthcare utilization of a defined and identifiable group of individuals within the context of a given organization. For example, a managed-care company might have a population health management program in which it provides all of its members who have a diagnosis of diabetes with a smartphone loaded with an app that sends daily reminders about monitoring their hemoglobin A1c level (and perhaps even reports the results to their primary care providers automatically). The company would have the denominator of all enrollees, the numerator of all enrollees with a diagnosis of diabetes, and a method of monitoring the health status of the individuals with the app. The managed-care company would therefore be able to determine whether the app made a difference in utilization of healthcare services or in the long-term health status of individuals or the aggregate population. The company might add the role of a health educator to show enrollees how to use the app and to be engaged as a health counselor. The role of the health educator could be a second intervention, and the managed-care company could compare the change in health status of enrollees who used both the app and the counselor with the changes in those who were given only the app. Such metric-driven interventions demonstrate classic population health management programs.

McAlearney (2003) identified six different types of PHM programs over 20 years ago. Hewitt, Mascari, and Wagner (2021) updated and expanded the list to add four more categories and delineate the criteria for a PHM program as having

a focus on clearly defined population(s);

an expanded continuum of care;

an emphasis on equity of access, quality, and cost;

new models of care that include risk sharing;

the ability to manage the relationship between cost and improved outcomes; and

an emphasis on integrated delivery systems that span cross-sector relationships.

Payment models for healthcare services have evolved over the past two decades from payment for volume of provided care to payment for value. As a result, implementing and managing population health initiatives have become increasingly important responsibilities for healthcare executives. Population health, including its relationship with current trends for payment mechanisms, is described in more detail in chapter 8.

Community Health

Community health is a much broader term than population health, and it can be ambiguous. Various definitions range from very specific to very broad. For the purpose of the cases in this book, community health can be defined as the health of a group of individuals who share a bond of geography, culture, race, ethnicity, language, sexual orientation, pastime, passion, or another common characteristic. Every community in the United States is unique in some way: the demographic characteristics of its residents, its environment’s topography and weather, its income status, its endemic diseases, its community agencies, its stakeholders and champions, and the roles that healthcare providers and payers play.

From a practical management perspective, community health is the opposite of population health. In many instances, community health programs offer no ability to measure either the denominator or the numerator. For example, a community coalition spearheaded by the American Diabetes Association but convened locally might develop an advocacy campaign to encourage all residents to be tested for diabetes and to improve their diets, with free screenings provided by the coalition members offered each weekend in rotating locations for a given month. Messages could be broadcast through public service announcements (PSAs) on radio or television, sent as text alerts, or disseminated through e-mail lists, with each organization in the coalition sending the message through its own media to its own constituents. The coalition would have no idea how many people in total heard or received the messages; hence, they would not have a denominator by which to measure the total reach of the advocacy campaign. They could record the number of people who appear at screening sites and the count, but not the identity, of the people whose tests indicated some level of diabetes. Because of the privacy constraints and resources required, the advocacy campaign would likely not follow those at risk to find out whether they sought care from a health professional, changed their behaviors to mitigate the risks of diabetes, or showed improvement over time in their health status. The community campaign thus might be able to report the total number of people screened, but it would not be able to show any direct relationship to change in the health status of individuals or the community.

An example of a community health program undertaken by a single organization would be a health fair booth at a local church at which a home care agency provides free screening for diabetes. The agency might have selected this approach because it knows that many members of the parish are Hispanic and that Hispanics have demonstrated high rates of diabetes and undiagnosed diabetes. The agency would have no idea how many people saw notices about the health fair (other than estimating based on the parish’s total membership or the fair’s total attendance), but it would have a record of how many people it screened and how many tested positive. Hopefully, the agency would also know how to contact those individuals whose test results called for active follow-up—but whether it had the resources and the incentives to do so would be another question.

As a result of the absence of evaluation metrics and methods, the success of a community health initiative in attaining its goals and objectives can be hard to demonstrate. This can cause challenges when trying to secure institutional commitment or resources for an intervention or trying to convince community members to participate. Regardless, improving the health of populations and individuals requires improving the health of the communities in which they reside.

The organizations driving community health programs include health systems, health provider organizations, social support agencies, housing complexes, nongovernmental organizations that focus on health, foundations, community coalitions, and others. As noted above, every community is different, and the relationships among those who are involved with health and healthcare differ. Power structures, levels of trust, methods for communication, history of collaboration—all vary from community to community. Cooperation and coordination with a variety of communities and the organizations that serve them—all of which have differing missions, clients, stakeholders, and resource sources—pose considerable challenges to healthcare executives, emphasizing the importance of knowing how to manage beyond the walls of one’s own organization. Community health is described in more detail in chapter 6.

Public Health

Charles Winslow (1920, 30) defines public health broadly as "the science and art of preventing disease, prolonging life, and promoting physical health and efficiency through