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Population Health

Driving Quality Outcomes: The Role of the Primary Care Practice in the Success of Population Health

A Message from Steven R. Carson, MHA, BSN, RN

As a primary care provider (PCP) treating one patient at a time, how often do you consider your work contributing to population health? What impact can a PCP have on the level of health of the community as a whole?

According to researchers at Duke University’s Department of Family Medicine and Community Health, population health refers to the health outcomes of a group of individuals, including the distribution of such outcomes within the group.

More and more, PCPs are being called upon by professional associations ranging from the Institute of Medicine and the American Academy of Family Physicians to the health systems of which they are a part, to lead population health efforts by attending to social and environmental determinants of patient health in addition to the medical.

At Temple Health, we too, recognize primary care as the driver of success in population health, furthering our goals of better care, healthier people, and smarter spending.

In the past decade, Temple Health’s Center for Population Health has developed experience and award-winning programs built on a combination of risk lives and care management programs. Today, Temple has approximately 90,000 lives in a shared risk agreement.

You, our Temple Care Integrated Network providers, enable our Center for Population Health to track and manage multiple data streams, including EMR and claims data, social determinants of health (SDOH) surveys, and data sharing through the regional Health Share Exchange. We conduct robust risk stratification to identify the patients most in need of specific services, track and improve outcomes, and coordinate healthcare services across health systems.

In addition, we are a leader in creating partnerships that address social determinants of health, improve access to healthcare, and support transitions through collaborations with providers such as PHA Cares, Farms to Families, the Healthy Together Mobile Health Vehicle, and many more.

We understand that success with the population health model requires delivering the right care, at the right time, in the right location. Success for risk-based population health requires avoiding preventable hospital and ER admissions and readmissions and delivering the highest-level care in the lowest-cost appropriate setting.

Our PCPs play a pivotal role in preventive healthcare, as MDs, DOs, and Advanced Practice Providers practice at the top of their licenses and manage higher-acuity patients outside the hospital setting.

Primary care partners also help us advance our goals for health equity. Researchers have demonstrated that primary care serves as a force for integration and personalization of medical care. By building long-term relationships that consider the whole person in their environment, PCPs are in the unique position of being able to connect patients who have complex or unexplained health problems to services not only across the health system but also with social services that address impediments such as food insecurity, housing instability, and other basic needs that can make medical services more efficient and effective.

By caring for patients’ needs, primary care yields improved health, equity, quality, and value at the population level of countries and systems. A primary care provider’s longitudinal, trusting relationship with the whole person -- as well as their family and community – yields considerably more than the sum of its parts.

Jennifer E DeVoe, “Primary Care Is an Essential Ingredient to a Successful Population Health Improvement Strategy,” J Am Board Fam Med. 2020 May-Jun;33(3):468-472.

Mina Silberberg PhD, Viviana Martinez-Bianchi, MD, and Michelle J Lyn, MHA, “What is Population Health?” Primary Care: Clinics in Office Practice, Vol 46, Issue 4, Dec 2019, pp 475-484

*Kurt C Stange, William Miller, and Rebecca S Etz, “The Role of Primary Care in Improving Population Health,” Milbank Quarterly: A Multidisciplinary Journal of Populations Health and Health Policy, Vol 101, No S1, 2023 (pp 795-840)

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