We began our study with two key assumptions. First, based on self-reported FTEs, we assumed that the hospitals had dedicated significant resources to population health initiatives. Second, due to some very large FTE numbers reported, we expected to find that these children’s hospitals were deeply involved in population health, from leadership to employees. Despite sharing a large number of FTEs devoted to population health, hospitals described disparate frameworks for understanding the role of population health in children’s hospitals. In particular, interviewees described three quite different approaches to population health: hospitals that exclusively used population health management strategies, hospitals that described their approach as population health, but are really focused on population health management, and hospitals that equate population health with public health. We have included additional participant quotations for each theme in Table
3.
Table 3
Additional Participant Quotations
Theme: Multiple Definitions of Population Health Operative in Children’s Hospitals |
Hospital | Quotation |
CH1 | “I always have to clarify that I mean population health versus population health management.” |
CH2 | “My concepts of population health are consistent with all children in this geographic area.” |
CH4 | “I think that people don’t have a solid definition of what is population health. Often times people are talking about...they may just be managing their population of asthmatics that are here…” |
CH5 | Population health is “a recognition that outcomes would never come without improvements to quality of life before kids enter hospital doors.” |
CH6 | “So many people define it differently...population health is developing a culture that will improve the overall health of a community...I don’t want to say it’s specifically just the patients...but the community. Improve the health of a community and decrease the health disparities. I would take the term ‘patients’ out of it.” |
CH8 | “We consider financing part of our population health function...as we grow health care plans and grow some of our own risk out there...launching a health plan for Medicaid children, the sickest of the sick...” (referring to health care plans as an example of population health). |
CH9 | “Taking full risk...ownership of the entire medical management of those lives...That’s the only way we’re going to truly change our outcomes.” |
Theme: Support for Population Health among Hospital Administrators |
CH1 | “We have not done a good job with population health measures...how do you make the case that a program is working and continue funding?” |
CH3 | “We’re going to need…if there is a fundamental recognition that health care is tied to socioeconomic factors…then government as a whole is going to have to drive money into those spaces more than they currently do.” |
CH4 | “I think it’s in an ongoing conversation...so it’s a continuum, right? We sort of, we weren’t there, but we’re making progress.” |
CH5 | “I think most people are coming along...there are definitely pockets of resistance. I joke about my area being an area that financial people hate...we are not the NICU revenue generator. We invest in the community, but certainly aren’t making that money back on the things we are doing in the community. That speaks to the hospital’s commitment to this..our board really integrated this into the strategic plan...really speaks to the majority of people coming along.” |
CH6 | Regarding their hospital mission: “Population health, rather than treating patients, is core to our foundation...I would love for us to add a fourth dimension to our [definition], but it’s falling on deaf ears…What pays off in the long run doesn’t keep the door open.” |
CH7 | “We’re still learning. I know there’s a lot of conversation that occurs in the executive suites when we talk about things like the social determinants of health.” |
CH9 | “I don’t see this ever being fully successful without that executive level commitment.” |
Multiple definitions of population health operative in Children’s hospitals
A key finding suggested the presence of considerable disagreement about the meaning of population health among the pediatric health care personnel we interviewed. Some hospitals specifically described ambiguity about and a lack of consensus over this term. As CH7 explained, “Population health means whatever you want it to, apparently.” Other hospitals described the meaning of population health as evolving within their hospital. CH6 said, “A year ago I’d give you a different answer, two years ago I’d give you a different answer, three years ago I’d give you a different answer….” Still, when pushed to provide a working definition, hospitals disagreed on whether population health referred to existing patients or the general populations of neighborhoods surrounding the hospital, or to more expansive geographies.
When describing their population health activities, some hospitals described what would most traditionally be defined as “population health management.” As CH9 explained, “if you ask 10 different people...you’re likely to get 10 different answers. Changing a hospital system of care to a full care model that extends to wherever patients might be...might mean schools, homes...really managing the patients we serve no matter where they are in the care continuum...both in terms of quality and costs.” CH8 described a similar focus on the health outcomes of existing patients, especially related to their ability to access appropriate services. They defined population health as, “Care coordination, care navigation… a lot of different buzzwords... but we consider all of those to be a part of population health.”
Other hospitals described work in public health, but described services traditionally identified with population health management. For example, CH4 described their hospital’s approach to population health as centering on their “integrated care system and so we within that system...manage over 100,000 Medicaid lives...and work with clinic and community practices.” This hospital described these largely managerial programs as concerned with “the health of the population,” akin to “more of a public health approach” than “direct clinical care.”
A third group of hospital employees explicitly distinguished their approach to population health from population health management. According to CH3, “Most hospitals when they talk about population health are actually talking about population management.” For this hospital, population health concerns “engaging in primary prevention and prevention programs in the community, with kids who hopefully never touch our hospital,” with the goal of using prevention, as “the entire aim of population health,” “to eliminate the need for hospital services.” According to an employee from CH5, population health concerns “the health of the population in our region,” which they admit “feels somewhat generic but obviously it is not just about treating disease, but it’s overall health indicators.” The employee from CH10 took a similar approach: “Many of those factors that drive health are most readily addressed at the population level, not at the individual level,” adding, “That’s why we embrace the more holistic definition of population health than the more traditional approach of condition management.”
Some of the hospitals pushing for a broader definition of population health argued that hospitals should expand their reach beyond patients and “focus on the city,” as the employee from CH1 put it. The CH5 employee similarly described population health initiatives in the “area around the hospital” as “priority one and sort of a testing ground for things we might want to think about taking to scale in the future…” Finally, the employee from CH2 pushed for a “broader sense of [population health]... looking at all the children we serve in that large geographic area…,” adding, “When people think of health care, they think about a hospital or a clinic... they don’t think about a community.” After compiling a list of hospital programs described by participants, the authors sorted these programs into categories of population health or population health management (Table
4).
Table 4
Examples of Hospital-led Programs across Sample
Community health workers visit repeat ER users | | X | Changes utilization behavior of existing patient populations |
Partner with schools to develop community gardens | X | | Addresses social determinants of health among general population |
Violence prevention | X | | Addresses social determinants of health among general population |
Patient advice line | | X | Provides follow-up information to existing patient population |
Follow-up telephone calls after birth | | X | Provides follow-up information to existing patient population |
Increasing contraceptive access in community | X | | Improves access to health care among general population |
School-based Clinics | X | | Improves access to health care among general population |
Improving patient data systems | | X | Provides comprehensive data on outcomes and quality of care related to existing patient population |
Improving affordable housing stock | X | | Addresses social determinants of health among general population |
Home visits for patients with positive lead exposure | | X | Provides follow-up information/care to existing patient population |
Patient and family advisory groups | | X | Provides follow-up information to existing patient population |
Developing ACOs: Risk-bearing and Population management models | | X | Changes funding models for existing patient population |
Supporting dental clinics in underserved areas | X | | Improves access to health care among general population |
Drowning prevention | X | | Promotes accident prevention among general population |
Developing walking trails for children | X | | Addresses social determinants of health among general population |
Referral services for patients | | X | Provides follow-up information/care to existing patient population |
Providing pre-school to at-risk youth | X | | Addresses social determinants of health among general population |
Support for population health among hospital administrators
Regardless of how participants interpreted population health, another recurrent theme suggests that building infrastructure for population health is a challenge in children’s hospitals. Although interviewees detailed various stages along the way in transitioning to population health work, a lack of consensus regarding the priority of this work was common. In some cases, evidence suggested that defining population health in terms of improving patient outcomes and preventing readmission was more easily integrated into hospital’s strategic plans.
For example, CH10 documented a “change from a hospital-centric approach to a patient-centered, community-centric approach, where our care is really based on managing an entire population regardless of kind of where they are.” For this hospital, which identified a large number of FTEs dedicated to population health work, “The majority of [those employees] are through those integrated services.” This transition required getting out of the traditional “hospital-based thinking” that population health frameworks challenge.
Similar hospitals whose work focused more particularly on patient outcomes described transitioning to population health management as less problematic than other approaches. For example, the participant from CH4 pointed to recent expansion projects related to population health, and new employees with titles specifically referencing population health who “work with clinic and community practices.” But moving to include non-patient populations and social determinants of health is more difficult and “an ongoing conversation.” This employee explained that while hospitals are a “key community player and economic driver for the community that they serve,” it is “hard to get involved in housing when you have children dying of cancer.”
Those hospital employees who defined population health more broadly shared additional challenges in redefining their hospital’s way of thinking. The first common challenge identified was convincing hospital administrators to focus on the social determinants of health and taking on additional risk in financing initiatives beyond direct patient care. CH5, for example, has taken on neighborhood-level economic development, and uses the surrounding neighborhood as a way to pilot interventions aimed at the social determinants of health. Unsurprisingly, within these population health contexts, there is often a pull back to traditional services since, as this interviewee noted, health care is “what we know best.” The CH2 participant added that population health interventions “require broad internal buy-in as well...Eventually we’ll get there,” but “people get frightened about what we’re trying to do” and ask “why are we paying for community health workers?”
A common worry concerned investing in population health if evidence was still limited about the efficiency and sustainability of such initiatives. Some participants expressed disagreement and frustration within their institutions about whether to take the leap from population health management to broader population health strategies. As an employee from CH6 explained, “They’re defining population in a business manner and only looking at the patients in front of them...in other words, we’re only going to treat patients with population health programs for which we have a business reason to do it. That really rubs me the wrong way. It’s because of the business...the money...we’re not going to build infrastructure when we have no reason to do it from a business standpoint...if you’re long sighted and care about the community…They’re all your patients eventually.”
Similarly, the participant from CH1 described challenges posed by population health, noting, “it’s much broader...we have limited funds…without immediate outcomes...it’s much more challenging to get more funds to support that” and “to decide how much risk to take on.” Internally, the goal is to “help try and shift people to become comfortable with risk.” Whereas population health management efforts, such as those concerning ACOs, are primarily focused on assuming various levels of financial risk within defined patient populations, the risk associated with population health concerns responsibility for outcomes in communities. These activities are often tied to tax benefits for non-profit hospitals and established through federally-mandated community health needs assessments. Unlike population health management initiatives, which involve financial strategies that promise savings, even if only in the long term, population health projects are generally considered to operate at a loss initially. They are, therefore, a somewhat more direct example of community benefit.
In addition to challenges, some hospitals shared success stories in establishing population health commitments. For example, an employee from CH7 explained that “our board prioritizes re-investing resources into their community...The real role of the children’s hospital in the community is to expand the capacity of the community.” The goal is “investing in the community to make it healthiest place to raise a child.” CH3 reported that the various stakeholders within their hospital are in agreement about the future role of the hospital in population health, stating that “population health is a key strategy for entire institution, and it goes all the way up to the board.” Among other things, this means that the hospital “board itself is engaged in the approval of needs assessments and plans tied to needs assessment.” Finally, a representative from CH10 explained that when they started laying the groundwork,
“The concept of what drives health outcomes was brand new. That was daunting, unnerving to colleagues. Helping the board understand why we need to approach this differently took time, but they were and remain committed to it. The natural expectation of a traditional hospital board is by what quarter should we expect these outcomes...these outcomes happen over generations, not quarters of a year. They are there now and I’m very fortunate to have this engaged and supportive board and research team.”
Some hospitals, in other words, had committed to engaging population health projects despite facing early challenges and internal disagreement.