Population health management focuses on understanding the health needs of the community, measuring and evaluating health status, and developing collaborative programs that will improve health outcomes. Health care and community leaders are shifting toward population health management by focusing on assessment, prevention, wellness, chronic disease management and other initiatives. Merging the resources and skills of hospitals and health care systems with community partners is essential for the integration and expansion of population health management programs.

Some small and rural hospitals already have established strong relationships with their communities — they integrate services with other local organizations and health providers. These relationships will prove advantageous for creating targeted population health management programs. It's true that small and rural hospitals must overcome challenges not encountered by urban providers, such as more patients with multiple chronic diseases and lower incomes, geographic limitations, and constrained financial resources. But small and rural hospitals and care systems can use their advantages to establish strong community partnerships for effective population health management.

Developing an Effective Partnership

If your health care organization has not yet established a successful working relationship with community partners for population health initiatives, start by:

  • conducting a community health needs assessment (for more information on conducting this assessment, access the Association for Community Health Improvement's Assessment Toolkit at http://www.assesstoolkit.org);
  • working with the community to synthesize the assessment results;
  • identifying potential community partners aligned with your health mission or objectives;
  • forming one or more partnerships to address health issues in the community.

Critical to the success of a population health program is an organized and structured partnership. For those health care organizations that are developing relationships with community partners, a downloadable Population Health Partnership Checklist developed by the American Hospital Association can provide guidance.

Case Example: Cheyenne Regional Medical Center

Cheyenne Regional Medical Center is a rural health care system headquartered in Wyoming's capital. In 2005, Cheyenne Regional helped to establish the Cheyenne Health and Wellness Center. Together the wellness center and the medical center provide a wide range of health care services: primary medical care, immunizations, diagnostic screening, family planning and more.

Building and sustaining a collaborative partnership. To better engage and treat patients with chronic diseases, Cheyenne Regional established the state's first safety net, patient-centered medical home in 2011. In two years, this medical home has improved access and health outcomes and has held down costs. For example, the number of female patients who received a Pap test rose to 68 percent from 19 percent. Body mass index has been recorded for 100 percent of patients at the time of their visits.

The wellness center implemented several plan-do-study-act cycles to successfully build chronic-disease management programs and to streamline processes, including those for medical referrals. The size of its patient population increased by 17.5 percent, but the average cost per clinic visit decreased by 20.8 percent.

Case Example: Wrangell Medical Center

The community of Wrangell, Alaska, has a population of 2,300 and is accessible only by airplane or boat. This scenic but remote location creates challenges for health care delivery. Wrangell Medical Center, the only hospital in the community and one of its largest employers, includes an eight-bed acute care unit and a 14-bed long-term care unit, along with an emergency department, lab and specialty clinics.

Increasing training and health screenings, and reducing costs. To meet Wrangell's economic and social challenges and to address the need for qualified nursing assistants, the medical center partnered with the local educational system to establish the Rural Health Careers Initiative. This program provides clinical education and training to interested students who receive mentoring and financial assistance for the yearlong course. The medical center prescreens applicants and offers hands-on training to improve students' educational performance. To date, this program has trained more than 200 students and saved more than $250,000 in education costs. The medical center employs the majority of students who pass the state certification exam.
Wrangell Medical Center also sponsors an annual community health fair, featuring more than 60 vendors in health, social services and education. Local businesses help with registration and marketing. The health fair has grown significantly and contributes to improving health outcomes for patients receiving health screenings. The number of individual screenings has increased from 761 in 2009 to 1,625 in 2013. Because these screenings are offered at a greatly reduced rate, the savings just this year to the community totaled more than $440,000.

Value of Strong Partnerships

By managing challenges and leveraging opportunities, small and rural hospitals and care systems can work with their communities to create flexible and customized population health programs. The impact of these programs can be significant due to the strength of the relationship between the community and hospital or care system. Effective population health management calls for building and sustaining strong partnerships. By marshaling their resources, small and rural hospitals or care systems and partner organizations can establish successful community health initiatives and improve population health.

Cynthia Hedges Greising is a communications specialist and Thomas Duffy is a program manager, both at the AHA's Health Research & Educational Trust.

For more information and case examples, visit the Hospitals in Pursuit of Excellence website at www.hpoe.org and access the HPOE guide "The Role of Small and Rural Hospitals and Care Systems in Effective Population Health Partnerships."