By Toni Cesta, PhD, RN, FAAN


Population health is the new buzzword in healthcare. Often misused or misunderstood, it is an important concept that applies to case managers and social workers across the continuum of care. Population health is now an integral part of what we do and how we think about our patients. No longer can we manage our patients “out the door” of the hospital and into the community with little thought as to what will happen to them once they get there — we must think about our chronic and high-risk patients beyond the walls of the hospital. So many of our reimbursement penalties and rewards have driven us in this direction, and if performed correctly, case management can steer our health systems and patients toward better health and outcomes. This month, we will discuss what population health is and how case managers play a strategic role in these emerging models of care.

Defining Population Health

Population health has a fundamental goal to help high-risk individuals with chronic conditions to remain as healthy as possible for as long as possible. A recent study indicated several determinants that are the foundations of a healthy population. These include health-related behaviors (30%), clinical care (20%), social and economic factors (40%), and physical environment (10%). Although as case managers we tend to focus on clinical care, it represents only 20% of the problem. In an effective population health model, we must provide ever greater attention to the other factors that clearly have much more to do with socioeconomic issues. While population health aims to reduce disparities among different patient populations, this concept still is not well understood. And despite the fact that these determinants have the greatest impact on how well a patient does in the community, healthcare commonly provides minimal — or none — of the resources necessary to address and manage them.

So, what is population health? It is an approach that aims to improve the health of an entire population. The population health concept represents a departure from most of mainstream medicine in that it is focused away from the individual patient level. It seeks to manage patients before they get sicker. It is a big concept to define and a bigger concept to implement.

In a population health approach, vast populations of patients are segmented, meaning that the healthy are separated from the patients who are chronically ill, frail, at end of life, or unable to manage their own health adequately.

These factors represent risk for these patients. They are at risk for poor outcomes, admissions and readmissions, and institutionalization. Population health strives to provide a greater focus on wellness and preventive services by staying ahead of problems. The concept is to risk-stratify the patients and focus resources toward those who score at greatest risk.

Components of Population Health

Fundamentally, population health is designed to coordinate care delivery across a population to improve clinical and financial outcomes. Three sets of tools are used to coordinate this care:

  • disease management;
  • demand management;
  • case management.

Disease management evolved out of managed care principles. It provides a system of coordinated healthcare interventions and communications for populations with complex conditions.

Access is an important component of disease management. It is the process in which patients with long-term conditions, along with family and caregivers, share knowledge, responsibility, and care plans with healthcare practitioners and/or peers.

Demand management is another component of population health that empowers patients to make wiser healthcare decisions. The goal is to engage patients in the quest for appropriate care.

The terms “adherence” and “compliance” often are used interchangeably in demand management. Adherence refers to the patient sticking to the proper practices of the care plan. Compliance occurs when the patient follows the instructions of the doctor. Adherence is a term that is commonly used in medicine to refer to the act of the patient, by him or herself, adhering to the proper dosage of medicine, proper practices of hygiene, or practices of well-being. In adherence, the patient is empowered and takes healthcare practices into his or her own hands via therapy sessions, self-care, or self-directed exercises.

Compliance, on the other hand, is defined as following the doctor’s instructions or recommendations in the care plan. It can seem like a paternalistic, uncaring, and condescending sort of medicine where the patient plays a passive role. Barriers to compliance include complex care management plans and poor health literacy.

In summary, adherence empowers the patient to become a co-equal to the healthcare providers, whereas compliance is believed to promote a paternalistic attitude toward healthcare. It is believed that adherence has more advantages than compliance.

Case management is the third tool in population health. Community case management incorporates both disease and demand management. It targets high-risk, high-cost subgroups in a population-focused framework. Community case management staff assist in managing and coordinating care for specific individuals across the continuum. These individuals are at greatest risk for suboptimal outcomes and typically cannot manage their care without the assistance of a healthcare professional, such as an RN case manager or social worker.

Case management provides a system of care that is used to oversee the care processes for these vulnerable populations. It also provides a linking mechanism to ensure that these patients are not lost to the healthcare system.

The first strategy is to keep patients connected to the healthcare system. Case management staff monitor and engage with the higher-risk patients as needed to ensure that appointments are kept, medication adherence is maintained, diets are well-managed, etc.

Problems patients face include the following:

  • missed treatments;
  • prescriptions not filled, not taken, or taken at the wrong dosages or frequencies;
  • missed medical or other healthcare appointments;
  • frequent ED visits or admissions;
  • frequent readmissions;
  • poor healthcare behaviors;
  • busy healthcare staff missing patterns or trends in these patients;
  • lack of systematic ways to assess and proactively deal with issues that affect adherence, quality of life, and outcomes.

Secondly, healthcare resources are matched to the patient’s needs. For example, a patient with greater behavioral health, financial, or social risk factors may have a social worker assigned to his or her case. A patient with a chronic and complex medical condition may have an RN case manager assigned to him or her. In some cases, extremely complex patients may require both disciplines working together to facilitate the best outcomes.

How to Develop a Population Health Strategy

Development of a population health strategy requires planning. Even before the program can be developed, your organization must be sure that it has the correct structural components in place.

• Provider networks. A comprehensive provider network that can support a population health strategy must include partnerships with care providers across the continuum, including ambulatory, hospital, and post-acute care. The best approach is to have a series of providers who are fully contracted with your health system. By contracting with providers across the continuum, the patient transitions can be performed seamlessly and without delays. Strong coordination of care and alignment of resources are critical and are foundational components of an effective plan. There is greater risk to a health system when employing population health, but this risk can be reduced through the use of a strong provider network.

• Provider compensation. Dovetailing with the need for a provider network is the need for a provider compensation structure. In the more traditional provider payment models, providers are compensated solely on the volume of work they perform. This model lacks incentives for providers to spend additional time with patients, provide education, or conduct patient outreach.

Even the notion of coordination of care gets short shrift in the traditional payment models for providers. A forward-thinking provider payment plan should include rewards to providers for meeting specific quality and cost measures. These incentives should include metrics for all specialties, including primary care.

• Payment models. There are a variety of payment models that will work effectively in a population health strategy. The systems with the greatest return include capitation and partial capitation payments. These mean that on a monthly basis, payment is made to the health system for services provided across the continuum of care. Capitation includes some amount of risk, as the monthly payment amounts must be carefully determined based on the population being managed. Bundled payments through the Medicare programs provide such payment models but are limited to a handful of diagnoses.

Value-based payment elements, such as the Spending per Medicare Beneficiary, require that resources and coordination of care are well-managed across the continuum. As these various payment models tend to collide in any health system, it becomes imperative that the fundamental infrastructure for the population health model supports all of them through care coordination, management of resources, and quality of care.

• Clinical informatics. Population health management of large numbers of patients would be impossible without information technology. The need for integration of clinical information across the continuum of care has never been greater. The first need is to establish a single electronic medical record that can be accessed by providers regardless of where the patient is receiving care across the continuum. This single medical record allows for better coordination of care, management of healthcare resources, and improved communication among providers. It is an essential component of population health.

Other important IT tools include patient registries. Registries are electronic systems that give providers and case managers methods to identify patients at high risk, who may need more intensive case management. They alert providers to abnormal test results and/or when tests, treatments, or procedures are due. Registries also alert case managers and support staff when a patient needs, or has missed, an appointment. With the large volume of patients that need population health, it would be virtually impossible to track and manage the copious amounts of patient information in any other way.

Risk stratification is best performed using clinical information systems that allow organizations and providers to understand the highest-risk populations they serve and to also report the quality and cost outcomes.

• Care models. As we discussed, care models such as community case management are important components of the successful population health program. Effective and efficient care models promote coordinated care across the continuum. These models should be designed to focus on those patients who are at greatest risk for poor outcomes and/or high resource utilization.

When we think of traditional models, we think of patients seeking healthcare services only when they are sick and seeking that care within the physical setting of healthcare. If patients are seeking care at multiple locations with multiple providers, it becomes the patient’s responsibility to ensure that all providers are receiving up-to-date and appropriate information.

Under a population health model, the patient is the central player in the process, and all care providers coordinate their care together and around the patient. The team usually is led by the primary care provider with supporting staff, including staff RNs, behavioral health providers, and others as needed. For those patients at higher risk, case management professional staff such as social workers and RN case managers, as well as other support staff, is added.

Team roles and functions also are critical in ensuring an effective population program. The multidisciplinary team must be involved in risk assessment, guidelines implementation, coordination of care, and self-management support. The primary care providers work to assist patients in optimizing their self-management when appropriate and/or referring to case management professionals when necessary. Educators and educational programs can help patients with these processes as well.

The Case Manager’s and Social Worker’s Role

The case manager’s responsibilities include the following:

  • advocacy and education;
  • clinical care coordination and facilitation;
  • continuity and transition management;
  • utilization and financial management;
  • outcomes management;
  • psychosocial management and support.

As advocates and educators, case managers and social workers ensure that the patient receives the services he or she needs, as well as any needed education. Patients will be more participatory in their care regimen if they understand the ramifications of not adhering.

Case management professionals coordinate the patient’s clinical care regimen and ensure that the patient is receiving those services in a timely manner. They work with the care team to update the patient’s care plan as needed and intervene when changes are necessary.

Case managers and social workers make sure that their patients have continuity in their care and that things are explained to them in a consistent manner. In addition, should the patient require services such as admission to the hospital, home care, or rehabilitation, the community-based case manager and social worker communicate with other care providers along the continuum to verify smooth transitions, that all providers are well-informed, and that the patient does not fall through the gaps as he or she transitions from one care setting to another. Transitional planning has become a key role for case management professionals as driven by bundled payments, value-based purchasing, and accountable care organizations.

Another key role for case management professionals is utilization and financial management. Managing resources has become an important component used to ensure that patients are not overtreated or undertreated. Managing resource consumption also helps the organization, as the use of limited resources is optimized.

Outcomes management is the next role for our professional staff. Case management professionals monitor and, if needed, intervene to achieve the desired outcomes for both the patient and the healthcare system.

One of the emerging issues is the concurrent management of medical and psychosocial issues. Because of this need, most community case management departments use both RN case managers and social workers to ensure that both sets of needs are met. These might include individual needs but also the needs of the family and home.


Population health is much more than just placing a case manager in a clinic or other setting. It requires an infrastructure of support that includes staff, information technology support, outcomes management, and strong communication across the continuum of care. While still in its infancy, it has many exciting features that will become more and more important in the years ahead.