For nursing education, particularly within associate degree curricula, population health is defined as learning activities that “address the assessment, intervention, and evaluation of populations impacted by social determinants of health, how health information and healthy behaviors is promoted to populations, how disease can be prevented through public education and policy influencers, and the nature, types and sources of evidence used to measure the overall health and wellbeing of a community and the populations contained therein.”
The nursing discipline has its core in caring for individuals, families and communities. Other health disciplines focus their practice and science on one or more aspects of care, whereas nursing frames its practice on holistic interconnections of body-mind-spirit.
Nightingale educated nurses to provide individual care, using science-based evidence and statistics to understand environmental influences on health and wellbeing. Her nurses modeled concern for the family, and her science encompassed the population. Nightingale understood population health before it was conceived and how it cascaded to drive patient and family-centered care.
Population health is a term that originated in Canada in 1997 to ascertain the health of a population as measured by health status indicators and influenced by social, economic, and physical environments, personal health practices, individual capacity and coping skills, human biology, early childhood development and health services. (Public Health Agency of Canada, 2013). The Institute of Medicine/National Academy of Medicine, the Centers for Disease Control and Prevention, and the Institute of Healthcare Improvement have agreed that a singular unified population health definition does not exist but each reference elements of the Canadian definition in their operational work.
The purpose of this paper is to provide a working definition of population health and population health management in the context of nursing education, particularly within associate degree nursing curricula.
Catalyzing Factors
The awareness of population health and population health management into the healthcare and nursing education vernacular results from a confluence of demographic, technologic, and political realities. From a demographic and cost perspective, the number of aging Americans has never been higher and these individuals live longer, are likely to have multiple chronic conditions, have survived conditions known as the social determinants of health, and desire a quality of life, all at an economic cost. Technologic and advances in treatment options have stimulated advanced care, but also – and this is important – electronic data capture that permits a level of health outcome data never possible in earlier decades. Finally, the Affordable Care Act, designed to foster access to care in systems where health data is captured, and with an eye toward reimbursing providers for prevention and health management, was passed in 2010 and rapidly has changed the political climate around health and wellbeing.
Many have documented that the U.S. healthcare system has been disease/illness oriented, with less emphasis on primary care and more on sickness care. The care system has evolved primarily based on the medical model linked to reimbursement of specialized care and end-of-life critical care. This model has not resulted in U.S. health outcomes that are comparable to other countries. In fact, the U.S. ranks moderately to poorly in many comparative indicators of health. The U.S. health system has many of the same institutions delivering care as in other modernized countries – primary/clinic care, hospitals, ambulatory care, hospice, long-term care, home care and others – however the funding of care has been predominantly oriented around physician and hospital reimbursement. The Affordable Care Act began the shift to a mindset of across-the-lifespan care that included prevention and care in less expensive settings.
Population Health in Nursing Education
Curley and Vitale state that the goal of population-based nursing is to provide evidence-based care to targeted groups of people with similar needs to improve outcomes. McAlearney states that the populations of interest must be defined, noting that populations can be stratified by age, income, geography, community, insurance coverage, and health status. She notes that age fosters assessment of appropriate health behavior and wellness strategies; income influences access to care and, when necessary, to lower cost clinics and sliding fee options; geography sets natural boundaries for interventions; community factors within a geographic area advances setting local community-sensitive health goals; employers form a worker-based population and/or provides health insurance for the employed population; insurance companies set policies that inform medical costs and can incentivize health management, and health status determinants are used to stratify into populations most at risk to benefit from interventions.
The Robert Wood Johnson Foundation plays a unique role in advancing the health of the nation.
They (RWJF) define population health in this way:
“While the definition of population health initially focused on outcomes, today it is used more broadly to include the collaborative activities that result in an improvement of a population’s health status. Upstream factors (determinants of health) – not just health outcomes – are included in measurement. There is a recognition that responsibility for population health outcomes is shared.”
They further define population health management more specifically:
“According to the Institute for Healthcare Improvement, it [populations health management] “orients payment and the delivery of health care services toward the achievement of specific health- care related metrics and outcomes for a defined population.”
Therefore, when the term population health is referenced, it can bear multiple meanings, including sub-populations (aggregates) to reference:
- an insured population, e., Medicare
- a geographic defined citizenry, e., urban, suburban, rural, frontier
- an age group, e., neonates
- individuals with health-related or disease conditions, e., congestive heart failure
- individuals of an ethnic, socio-economic, religious, or cultural group, e., African-Americans
- an employment-based group, e., coal miners
The focus of nursing assessment, intervention and evaluation in population health management is not at the individual or family level, even though population-based efforts may be implemented with an individual/family in mind. Rather, the key principle in population-based care draws a parallel from concept-based nursing: it uses evidence collected from individuals that is then aggregated to determine patterns that apply across populations and which would only be discoverable by examining the larger patterns and trends. Evidence-based standards of care and practice evolve to direct resources from a macro-level analysis to the micro-level point-of-care. Big-data – amassing and analyzing clinical, economic, access, and other types of data – allows new ways for discovery, adding to knowledge development and implementation.
Population health also is based on the principle of disease prevention and health promotion, with acknowledgement of the individual benefits derived from the absence of illness and the aggregate impact on avoiding high-cost scenarios in acute care, lost wages, family burden and role shifts, and more.
Developing a Population Health Mindset in Nursing Education
For nursing education, particularly within associate degree curricula, population health is defined as learning activities that “address the assessment, intervention, and evaluation of populations impacted by social determinants of health, how health information and healthy behaviors is promoted to populations, how disease can be prevented through public education and policy influencers, and the nature, types and sources of evidence used to measure the overall health and wellbeing of a community and the populations contained therein. Population-based evidence guides individual and family care, frames the importance of patient/family education, and informs the need for discharge planning and referrals to community-based support services. Learners are exposed to the methods used by scientists who collect and stratify data to create the body of knowledge needed for evidence-based practice yet it is beyond foundational nursing education to design, analyze, interpret, and draw conclusions from population data.”
Much of nursing education begins with individual and family-centered care, generally in the acute care environment where most nurses work. Critical thinking is applied from basic to advanced assessment and skill development, and results in safe care delivery in increasingly complex settings, where an evaluation of the impact of care is ascertained. As nursing science expands, care is increasingly evidence-based from research conducted across targeted patient populations, then applied to individuals and families.
Foundational nursing education acquires a population health management mindset in these exemplars:
- Holistic approaches to care – considering individual, family, and community as one – is the foundation for education and socialization into the profession
- Concept-based knowledge, congruent with population-based knowledge form the principles for care delivery as learners resonate with the influence they have on individuals, families, and communities
- Health promotion and disease prevention are essential to population health and are incorporated into care regardless of the setting
- Didactic presentations address population-based care management strategies and principles that link to clinical experiences at the individual, family, and community level
- Clinical documentation is a contributor to the data base which will be eventually aggregated through electronic health records, making the importance of valid and reliable charting
- Planning care transitions from one setting to another should include consideration of aligning patients and families with agencies that emphasize population health
Similarly, foundational nursing education does not emphasize:
- Data aggregation and analysis to formulate population-based standards of care and practice
- Evaluating population-based research
- Generating population-based data to influence health policy
- Developing IT strategies for population health
Summary
Multiple definitions exist for population health. Population health has a decided focus on health promotion and disease prevention and the ability to aggregate the care provided in individual clinical events to the patterns of care that transcend to meet the needs of populations. This enriched perspective adds depth and breadth to nursing judgment. Nurses who apply this community perspective can do so in any clinical setting, using evidence-based practice and epidemiologic-based critical thinking, focusing on prevention and documenting care with an eye toward their contribution to outcomes management.
REFERENCES
Cupp Curley, AL (2012). “Introduction to Population-Based Nursing” in Cupp Curley, AL and Vitale PA Population-based Nursing: Concepts and Competencies for Advanced Practice. New York, NY: Springer Publishing.
Public Health Agency of Canada (2013). “What is the Population Health Approach?” Updated January
- www.phac-aspc.gc.ca/ph-sp/approach-approche/appr-eng.php.
McAlearney, AS (2003). Population Health Management Chicago, IL: Health Administration Press
Robert Wood Johnson Foundation (2017) Catalysts for Change: Harnessing the Power of Nurses to Build Population Health in the 21st Century.
Institute of Medicine (2014) Working Definition of Population Health. Retrieved August 2 http://nationalacademies.org/hmd/~/media/Files/Activity%20Files/PublicHealth/PopulationHealthImpr ovementRT/Pop%20Health%20RT%20Population%20Health%20Working%20Definition.pdf
Kindig, D & Stoddart, G (2003) American Journal of Public Health March, 93(3): 380-383 Retrieved August 2, 2018 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1447747/
Wilson, ML, Weaver, CA, Procter, PM & Beene, MS (2018). Big Data in Healthcare: A Wide Look at a Broad Subject in Delaney, CW, Weaver, CA, Warren, JJ, Clancy, TR & Simpson, RL (eds.) Big Data-Enabled Nursing: Education, Research and Practice. Cham, Switzerland: Springer International.
Approved by the OADN Board of Directors 11/08/2018
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