Population Health Management

Local Priority Setting
Local priority setting entails the translation of national or regional policies into local strategic action plans that respond to the burden of disease and needs and preferences of the population.
Community Engagement
Community engagement is a process of developing relationships that enable stakeholders to work together to address health-related issues and promote well-being to achieve positive health impact and outcomes. Community engagement plays a critical role in planning and delivering services that are person-centered and responsive to population health needs.(1) Stakeholders should comprise multiple communities including community members, patients, health professionals, policy-makers and other sectors.
Empanelment
Empanelment (also referred to as population registration or rostering in some areas), a necessary aspect of primary care delivery, is an ongoing and deliberate set of actions to identify, match, and actively review and update data describing a group of people for whom a healthcare organization, care team, or provider is responsible. Additionally, both patients and providers are aware or their relationship. The listing is actively reviewed and regularly updated to ensure accuracy.
Proactive Population Outreach
Proactive population outreach involves health systems actively reaching out to communities, particularly those that are underserved or marginalized, to provide necessary services aligned with local priorities and burden of disease, and link those in need to primary health care. Examples of proactive population outreach include mobile health units, transport systems, health based care, telemedicine and proactive follow-up with patients chronic illness.

Step 1: Empanel the target population
To achieve effective population health management, providers or care teams must be able to list and locate the patients for whom they are responsible. Thus, empanelment – the assignment of a population of patients to a provider or care team - is a logical starting point and a necessary organizational structure for population health management. ¹ While empanelment can serve as an organizational foundation for effective population health management, it may not be easily implemented in all settings. In these situations, empanelment should remain an aspiration, but other population health management activities can be implemented at the same time.
Populations may be empaneled in a variety of ways, including by geography, voluntary enrollment, or insurance scheme. Ideally, the entire population within a given area should be empaneled to provider teams. This may be difficult or impossible in dense urban areas, areas with large and transient migrant populations, and areas with large numbers of private PHC providers who do not coordinate with a government or larger organizational entity. However, empanelment in mixed public/private PHC systems is possible. ² While a country works towards achieving complete empanelment, stakeholders may choose to start by empaneling certain subgroups of a population with specific health needs.
Step 2: Use panel data to inform local priority setting
After a population is empaneled, providers can shift their focus towards proactive care and health management. Data and registers from the empaneled population can help providers to track the health information of individual patients, plan public health services such as immunization campaigns, and explore indicators of access, utilization, and health outcomes that in turn inform local priority setting. ³ The identified priorities will define the mix of services and medical expertise necessary to manage the patient panel.
Step 3: Based on identified priorities, design systems for outreach in communities and homes
After identifying priority services, decision-makers and implementers can work with communities to determine which services would be most effectively delivered in communities and homes. Often, preventive care or education-based interventions are best suited to community-based care. Ideally, all people would receive proactive care in their communities, but often it may be more feasible to start with specific groups that require special care or attention, such as pregnant women, people with chronic diseases, or children. When planning proactive population outreach, implementers must consider which cadre of provider would most effectively deliver these services based on cost effectiveness, availability, and training. Community members should be consulted throughout the planning process to ensure acceptability of services.

View case studies for:

The Community Health Planning and Strategy (CHPS) program began as a pilot in 1994 and has since been scaled across Ghana, increasing access to community-based primary health care services.

Costa Rica’s primary health care system is supported by robust care teams that provider community-based care to an empaneled population. As a result, health outcomes in Costa Rica are consistently strong and improving.

The Family Health Program was established in Brazil in the 1990s. Under this program, Family Health Teams are responsible for a geographically empaneled group of households.

Relevant resources

Many tools and resources focused on population health management strategies have been created over the last decade. Below is an interactive resource that provides the most useful documents within the context of our defined scope of community engagement, local priority setting, proactive population outreach, and empanelment.

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COVID-19
NCDs and mental health
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PHCPI is a partnership dedicated to transforming the global state of primary health care, beginning with better measurement. While the content on this website represents the position of the partnership a whole, it does not necessarily reflect the official policy or position of any partner organization.

References:

WHO. WHO Community engagement framework for quality, people-centred and resilient health services. World Health Organization; 2017.
Black RE, Taylor CE, Arole S, Bang A, Bhutta ZA, Chowdhury AMR, et al. Comprehensive review of the evidence regarding the effectiveness of community-based primary health care in improving maternal, neonatal and child health: 8. summary and recommendations of the Expert Panel. J Glob Health. 2017 Jun;7(1):010908.
Sarrami-Foroushani P, Travaglia J, Debono D, Braithwaite J. Implementing strategies in consumer and community engagement in health care: results of a large-scale, scoping meta-review. BMC Health Serv Res. 2014 Sep 18;14:402.

Population Health Management

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