TABLE 1—
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 |
Community can also equal geographic area.