Community Outreach: Essential to Population Health Management Success


By Phil Suiter

There’s no such thing as a “cookie cutter” approach to population health management (PHM). Programs vary from one organization to another based upon culture, market dynamics and available resources. But there is one vital common denominator: the ability to reach out to the entire community, not just those who are currently patients.

That’s why many health systems are now proactively partnering with local employers and community groups. Their main objectives are:

  • Developing an accurate picture of community health trends (e.g., high incidence of obesity, diabetes, smoking, etc.).
  • Identifying community members who are most at risk of developing chronic diseases.
  • Providing upstream education, intervention and appropriate hospital services to help prevent individuals from developing those chronic diseases.

Key elements of a successful partnership: 

Provider target area employers and community groups, offering the expertise to create healthier,   organizations, reduce insurance premiums and lower absenteeism. They works directly with each group to conduct health risk surveys and biometric screenings, often including spouses and family members. This data is analyzed in a variety of ways and becomes the basis for provider-sponsored health management programs to address the organization’s health challenges at both group and individual levels. Participants receive a personalized health score, health risk profile, and content tailored to address their specific health issues or conditions that can lead to chronic illness.

This becomes the foundation for a consumer-facing population health website that participants can easily access. To maintain confidentiality, only the participant and the provider have access to Protected Health Information. An employer, however, receives an aggregate view of employees’ health along with a financial analysis tool that details the cost associated with current health risks and identifies potential savings that may be realized from various health initiatives. Here is where the partnership gains traction as the health system and employer team to create targeted, cost-effective programs for materially reducing health risks. Employers can also track, manage and evaluate incentive offerings.

Productivity gurus have long told us that “anything you measure can be improved.” This is certainly true for the PHM programs where leadership has taken the time to measure Return on Investment (ROI). Research shows that when metrics are in place, a PHM program’s ROI is between 2:1 and 3:1.1

New Ways To Connect With Consumers

These innovative provider/employer alliances have also taught health systems how to reach out more effectively to those outside the workforce, including the “unserved” market – individuals who are capable of making health improvements if given the right education, encouragement and access to primary care.

It’s possible to reach the community at-large in a variety of ways: through civic groups, faith-based organizations, educational associations, and even “fun runs” and county fairs.

Offering personal health assessments and biometric screenings at community events serves a dual purpose: helping individuals get a clearer picture of their health while allowing the provider organization to initiate relationships with them.

Consumer-facing population health websites – although they’re usually provider-branded – have a much different purpose than an Electronic Health Record (EHR). They enable consumers to record baseline metrics, set goals for health improvement, track their progress, and access resources on their journey toward better health.

Research shows that technology-aided consumer health engagement is rapidly gaining acceptance2:

  • Over three-quarters of Internet users are looking for health information online.
  • 77 percent are comfortable sharing health information online.
  • 60 percent track weight, diet, and exercise.
  • 33 percent monitor health indicators like blood pressure and sleep patterns.

Most impressive are the findings that 40 percent of respondents say tracking has led them to ask questions of their doctors, and 34 percent say it has affected how they seek treatment for an illness or condition.

Population health websites also offer significant marketplace advantages for providers. By linking them with consumers on a pre-primary care basis, there’s a foundation of trust that carries across the entire care continuum. This becomes important in the post-acute environment after hospital discharge, when higher risk patients need more attention to avoid a costly readmission.

Growing Importance Of Data Analytics

When data from population health websites gets integrated into provider EHRs, the wealth of information helps guide both clinical and financial decisions. Data analytics can provide advantages like these:

More accurate picture of community health – Providers can learn a lot about the health needs of area consumers who aren’t currently their patients – and help bring them into the system. There are often a significant number of community members (often as high as 30 percent) who do not have a primary care physician and are overdue for getting important health screenings such asmammograms, physical exams and cholesterol checks.

More effective risk management – By analyzing real-time and historical data, provider organizations can conduct sophisticated risk-stratification, helping prepare them for the new world of value-based care.

Customized programs to fit community budgets and readiness – The local hospital or health system understands the unique needs of area consumers because they’re all part of the same community. If obesity is a local problem, the provider and partners can specifically address it. Local providers also understand the community’s budgetary constraints and overall readiness for population health management. Some partner organizations are just getting started, while others have already begun biometric screenings and targeted educational seminars. A few may even be ahead of the curve, with incentive programs and an on-site nurse practitioner.

Incentive programs that really work – New technology platforms make it easy to engage consumers, manage incentive programs and measure their effectiveness. Web-based solutions offer consumers a personalized component with tools and resources to support their health goals – even delivering content tailored to their health risks and objectives. Participants can keep tabs on their incentive status/progress, access health trackers linked to activity devices, and log their diet, water intake, and exercise data.

A Healthy Community: The Ultimate “Competitive Advantage”

PHM programs that actively move outside the four walls of the hospital deliver benefits to all stakeholders:

  • Healthcare providers benefit from establishing strong relationships with local residents that positively impact community health while driving activity to their primary care physicians and service lines.
  • Employers benefit from a healthier, more productive workforce and lower insurance premiums.
  • Community members benefit by making steady health improvements and enjoying life more fully.

By forging strong ties with area residents and employers, healthcare providers are helping implement the most profound change in medicine in decades: moving from “sick care” to wellness and preventive care (as seen in the chart below).

It’s a shared journey that benefits everyone in the community – and it all begins with providers’ outreach and energy.

Phil Suiter is President &CEO of Aegis Health Group, headquartered in Brentwood, Tenn.


  1. International Foundation of Employee Benefits Plans, 2012
  2. Pew Charitable Trust research, 2013




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