Population health is fundamentally about measuring health outcomes and their upstream determinants and using these measures to coordinate the efforts of public health agencies, the healthcare delivery system, and many other entities in the community to improve health. These measures monitor how well we are managing a responsibility that we all share, and help to set priorities. Managing a shared responsibility, however, is challenging: given the many factors that influence health, no single entity can be held accountable for health outcomes. But as I came to realize in preparing a new Academy Health issue brief on population health, what seems like a minor component of the Affordable Care Act (ACA) provides the key to resolving this dilemma.
The IRS now requires that all non-profit hospitals conduct Community Health Needs Assessments (CHNA) in conjunction with local health departments and others. CHNAs must identify existing health care resources and prioritize community health needs. Hospitals also must develop an implementation strategy to meet the needs identified through their CHNA and a set of performance measures to track progress.
These requirements are mirrored in the Public Health Accreditation Board’s (PHAB) standard mandating that health departments participate in or conduct a collaborative process resulting in a comprehensive Community Health Assessment. Other PHAB standards require that they conduct a comprehensive planning process resulting in a “community health improvement plan,” assess healthcare service capacity, identify and implement strategies to improve access to healthcare, and use a performance management system to monitor achievement of objectives.
Thus, although the language is different, both IRS and PHAB call on hospitals and health departments to collaborate, and propose a similar measurement strategy for improving population health. As quality measurement did in healthcare, performance measurement has the potential to transform population health, but only if the right measures are used.
Two different sets of measures are needed, as articulated in the 1997 Institute of Medicine report Improving Health in the Community.
To coordinate a community’s efforts, this IOM report proposed a Community Health Improvement Process (CHIP) that begins with a CHNA to summarize a community’s overall health status, for which public health agencies, healthcare providers, and many other community stake holders share responsibility. The community health profile -- another term for CHNA or CHA -- is highlighted in blue in the upper “Problem Identification and Prioritization cycle” in the figure shown above. This profile is used to identify specific activities to be conducted by different entities in the community (public health, health care providers, employers, schools, and so on) that contribute to the overall community health goals. Because comparisons can help to identify priorities, a standard set of measures, such as those developed for nearly every county in the United States by the County Health Rankings, is a useful starting point.
To manage this shared responsibility, communities should develop a set of valid and actionable performance measures to ensure that the entities are held accountable for their activities. Identifying accountability for specific actions is an essential component of both the Community Health Improvement Plan required by the IRS and the comprehensive planning process in the PHAB standards. The IOM CHIP model includes the red-highlighted “indicator set” in the “Analysis and Implementation” cycle. A more recent IOM report, For the Public’s Health: The Role of Measurement in Action and Accountability (2010) lays out a very useful “Framework for Accountability” suggesting specific measures and the stakeholders (or accountable entities) associated with them. For instance, if the goal is to address diabetes, the measures might include the availability of recreation facilities and physical education programs to hold the parks department and schools accountable, as well as screening for diabetes and glycemic control in diabetes patients to assess the healthcare sector’s contributions. Both improvement plans and their associated performance measures must be tailored to a community’s health needs and improvement activities, so a standard set of measures is not desirable.
Michael A. Stoto, PhD, is a Professor of Health Systems Administration and Population Health at Georgetown University, and currently serves as a Senior Scholar in Residence at AcademyHealth.
Institute of Medicine (IOM). 1997. Improving Health in the Community: A Role for Performance Monitoring. Washington, DC: National Academies Press.
IOM. 2010. For the Public’s Health: The Role of Measurement in Action and Accountability. Washington, DC: National Academies Press.
Stoto, M.A., Population health in the Affordable Care Act Era. AcademyHealth Issue Brief, February, 2013.