TABLE 1—

Characteristics of Various Approaches to Population Health in Accountable Care Organizations

Approach	Focus on Individual Patients in Primary Care Settings	Panel Population = Population Health	Communitya Population = Population Health
Medical home	May or may not have medical home	Medical home implemented	Medical home implemented
Care coordination	Focuses on coordination within primary care setting	Focuses on coordination within delivery system and potentially some community resources	Focuses on coordination within delivery system and all community resources
Clinical prevention services	Implement all clinical prevention services in primary care	Implement all clinical prevention services in primary care	Implement all clinical prevention services in primary care
Community prevention services	No implementation of community prevention services	Limited implementation of community prevention services	Full implementation of community prevention services
Health indicators monitored	Measures for provider settings, but no alignment with delivery or community or public health systems	Measures for patients in the delivery system, but no alignment with community or public health systems	Measures for delivery system include measures at the community population level
Needs assessment	No attention to community needs assessment—focus only on primary care settings	May have some joint needs assessment but focuses on decisions within the delivery system	Joint needs assessment related to community population outcomes and joint selection of target areas for action
Relationship to public health system	No relationship	Coordinating structure may exist with public health	Governance and coordinating structures in place with public health agencies to improve community population health
Relationship to community agencies	No relationship	Coordinating structure may exist with some agencies to promote health for patients in delivery system	Formal coordinating relationships with community agencies to share community population health goals
Use of community health workers	Use within primary care system with little link to community	Use to coordinate across delivery system and some community resources	Use in clinical and community settings to improve community population health for all individuals in the community.
Financing for population health initiatives	None within a fee-for-service system	Limited financing within fee-for-service system; community benefits supports limited activities with community; special grants and demonstrations but no dedicated source	Increased financing for public health entities through state or federal streams or Prevention Trusts; global fee systems for delivery systems commit 5% to community population health outcomes
Governance to promote population health	None in place in primary care setting	Limited governance structures in delivery system; might participate on community coalition or in informal partnerships	Formal governance structures in place with community and public health agency; delivery system has a designate senior lead for population health and dashboard measures on population health

^aCommunity can also equal geographic area.