Population health approach puts health care services into context.

Population Health focuses on a group of individuals, the “population”, to be treated.  Population health also looks at what are called the social determinants of health such as housing, supported employment and social support.

In 2016 Jefferson Healthcare began looking at population-level interventions, specifically ones associated with the social determinants  of health.  The Population Health Department was formed in 2017 and the 2019-2020 Strategic Plan focuses on three portfolios of work:

Housing

In 2017, Jefferson Healthcare received a grant from the WA Department of Health to evaluate the role of hospitals in housing.  Jefferson Healthcare will be partnering with OlyCAP and others to implement a housing pilot for our most vulnerable patients.

Food

Jefferson Healthcare is committed to providing healthy food to our patients, staff and the broader community.  This portfolio is specifically looking to address food insecurity in Jefferson County, which effects over 4,000 people in our community.

Friends

Social isolation, or being lonely, has significant impacts on health, including an increased risk for chronic diseases, poor mental health, hospital readmissions and other negative outcomes.  This portfolio is exploring the feasibility of an inter generational program for adults and children to address social isolation in our community.

Financial Impact

As the move to value-based care continues, health systems are becoming increasingly responsible for the total healthcare spend of their community.  Investing in upstream interventions to keep patients out of the hospital will be critical as Jefferson Healthcare takes on more financial risk.  As a small rural hospital, Jefferson Healthcare cannot invest in all of the social determinants of health, so we have identified those that have both immediate and lasting impact.

Objectives
  • Characterize population needs
  • Implement programs that address the social and economic factors that influence health
  • Support clinical gap closure
  • Coordinate community-wide projects
  • Promote a data-driven culture
Healthcare in the United States is undergoing a cultural shift.
  • Prevention becomes the driving force in healthcare
  • Investment in early interventions including social determinants of health
  • Quality scores
  • Data investments
  • Quality in population health management