Whole Community Care

The field of population health evaluates the health outcomes of a group of individuals with the goal of optimizing those outcomes to create a healthier community.  Population health focuses on social determinants of health as primary factors influencing health. Determinants can include poverty, housing, employment, food security, social cohesion, and community safety.

In 2016 Jefferson Healthcare began looking at population-level interventions, specifically ones associated with the social determinants  of health.  The Jefferson Healthcare Population Health Department is positioned to create the bridge between traditional, individual medical care and healing the social needs of our community.

The department works to expand the boundaries of health care delivery by designing and implementing projects to address determinants of health.


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.


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.


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.

Early Life

Lifelong health is determined to a great extent by prenatal, infant, and toddler exposures and experiences.  This portfolio explores family supports in the early years.  A pilot safe sleep program provides baby boxes to expecting parents, modeled after a program in Finland that started in the 1940s.

Advocacy for increasing the amount of high-quality child care in Jefferson County is another primary focus.  The Population Health Department partnered with Peninsula College and the Olympic Peninsula YMCA and obtained a Washington State Department of Commerce grant to fund a county child care needs assessment, feasibility planning, and program development to address gaps in child care availability.

Interventions to lower costs and improve health

There is a growing emphasis on creating health without increasing spending.  Incorporating strategies which move beyond whole-person-care to whole-community-care will be an effective and fiscally responsible mechanism for improving health in a population.

The cultural shift for healthcare

The Institute for Healthcare Improvement’s Triple Aim recommends health systems redesign to improve patient experience, decrease costs, and improve the health of whole populations.  Population health strategies at the local level is key to meeting Triple Aim goals.

Rural health systems can work nimbly with colleagues and community agencies to make a targeted difference in community health.

Jefferson Healthcare’s population health strategies


Population Needs
  • Publish community profiles of county sub-populations
  • Highlight differing needs to focus strategic planning
Social Factors
  • Focus has been housing, food insecurity, and social isolation
  • Explore expansion to transportation, employment, and early life
Clinical Gaps
  • Integrate behavioral health into primary care teams
  • Establish dental care services for low-income residents
  • Create medication assisted opiate addiction treatment program within primary care clinics
  • Embed full spectrum reproductive health into primary care
Advocacy and Policy
  • Advocate for expanded allowable services within rural health clinics and modernizing rural payment structures
Community-Based Projects
  • Partner with Community Health Improvement Plan and Olympic Community of Health to implement and expand community-wide programs
Data-Driven Decisions
  • Partner to develop a centralized data team and provide statistical expertise to decision making