A Framework for Population Health

While health care leaders increasingly recognize the opportunity to improve the health of the communities they serve, the pathways to do so remain the roads less traveled. We have developed a Pathways to Population Health Framework to help chart the paths towards progress in population health.

In the words of one CEO, “I’m on the bus for population health; in fact, I’m driving the bus. But I need help shifting my core business—all of which focuses on sick care—to focus on creating health and well-being. I need a roadmap to help me know how to do that.”
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Foundational Concepts

These six concepts help lay the foundation for the pathways towards population health and articulate several of the reasons many health care organizations have chosen to embark on this journey.

  • What Creates Health
    • Health and well-being develop over a lifetime.
    • Social determinants drive health and well-being outcomes throughout the life course.
    • Place is a determinant of health, well-being, and equity.
  • How Can Health Care Engage
    • The health system can respond to the key demographic shifts of our time.
    • The health system can embrace innovative financial models and deploy existing assets for greater value.
    • Health creation invites partnership because health care is only one part of the puzzle.
Foundational Concepts

Common Language for Population Health

The Pathways to Population Health Framework provides a suggested list of key definitions in an effort to increase fluency in the field.

Common Language for Population Health

Portfolio of Population Health

The Portfolios of Population Health framework presents four interconnected portfolios representing the comprehensive scope of what is needed to improve the health and well-being of populations and communities. These portfolios connect and build upon one another and are intended to represent a balanced portfolio of population health efforts that could be part of a health care organization’s overall population health improvement strategy. For meaningful transformation to occur within and across portfolios, it is vital for health care organizations to address equity and to partner with those with lived experience.

Portfolio of Population Health

Key Levers for Implementation

Considerable challenges and opportunities lie in operationalizing the Portfolios of Population Health. Key Levers for Implementation proposes actions across a set of key levers deemed vital to accelerating improvements within and across portfolios.

Key Levers for Implementation Key Levers for Implementation
“Children born in the same hospital who grow up two miles apart might have a 10- to 25-year difference in predicted life expectancy because of place-based determinants of health.”
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