Growing evidence demonstrates that social determinants of health, such as housing and education, are at least as important as medical services in generating health outcomes. At NYC Health + Hospitals, the largest public health care system in the United States, I have helped design a strategy around population health, a more proactive approach to addressing avoidable human suffering. Four principles undergird the strategy:
1. Local health systems must identify the group of patients for whom they are accountable. While this attribution of patients to clinicians — for instance through “accountable care organizations” in the United States — may seem straightforward or mundane, it is fundamental to systems setting up care models that are not solely contingent on patient visits.
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2. Effective health systems are increasingly grounded in high-quality communitybased care. Of the 218 essential, cost-effective interventions identified by the Disease Control Priorities Network, 140 are delivered through primary care centers or community- and population-based approaches, rather than through hospitals.
3. Due in part to the evolution toward community-based care, health systems around the world are starting to “meet patients where they are,” both physically and in terms of their health trajectory. Technology — particularly telehealth mechanisms such as text-messaging and phone or video consultations — enables the delivery of care remotely.
4. A principle common to convergent health systems is the use of data to guide care delivery and drive improvement. Valid, actionable data is lifeblood for health systems to both motivate change at the front lines of care and to monitor overall performance.
