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. 2019 Apr 11;19(2):5. doi: 10.5334/ijic.4197

Table 4.

Interventions used to support population health elements and address the social determinants of health.

Population health elements Focusing on health and wellness, prevention rather than illness Addressing the social/multiple determinants of health Taking a population rather than an individual orientation Embracing intersectoral action and partnerships Addressing equity/health disparities/health in vulnerable groups Understanding needs and solutions through community outreach Adopting a long-term approach in care planning and delivery
Determinants of health Interventions
Income and Social Status

  • Referral to welfare agencies by case manager (Embrace)

  • Access to income support (Healthy Homes)

  • “Navigator” or “integrator” help members connect with community-based social services (Kaiser Permanente)

  • Referral pathways supported by teams of referral and health, and social care co-ordinators and information technology (Torbay)

  • Access to healthy foods via community kitchens (Spokane, Kaiser Permanente)

  • Help with financial deprivation by improving access to welfare agencies (Healthy Homes, Embrace)

  • Regular community meetings to identify needs and support referrals to welfare agencies (Embrace)

  • Addressing system-level barriers perpetuating health inequalities (Spokane)
Social Support Networks

  • Creating social support networks via socialisation of elderly (KAPI)

  • Promoting social participation and preventing social isolation (Zijloevern)

  • Social case management (social workers support patients with complex social problems) (Gesundes Kinzigtal)

  • Referral pathways supported by teams of referral and health, and social care co-ordinators and IT (Torbay)

  • Discharge streamlined with systematic follow up within 72 hours and “Welcome Back Home” package from social care staff (Jönköping)

  • Referral of diabetic patients to neighbourhood support groups (Healthy Homes)

  • Fostering of “working together” among networks of Alaska Native and other providers and customers-owners (Nuka)

  • Physical exercise through social networking – KP Walks and Every Body Walk programs (Kaiser Permanente)

  • Red Cross, Caritas, Volkshilfe, district hospital coordinate network of social and health care providers (Hartberg)

  • Family Wellness Warriors Initiative – weekly support groups and gatherings for victims of abuse and neglect (Nuka)

  • Group meetings (life cafés) to discuss how to improve different aspects of health and well-being (Jönköping)

  • Learning cafés to connect people with similar conditions and draw on expertise of “expert patients” (Jönköping)

  • Referral to welfare agencies via regular community meetings (Embrace)

  • Fostering of ownership and governance from networks of Alaska Native providers and customers-owners (Nuka)
Education and Literacy

  • Enrolling children in early childhood education and ensuring school attendance (Healthy Homes)

  • Family Wellness Warriors Initiative – education on prevention of abuse and neglect (Nuka)

  • School interventions via Thriving Schools and the Fire Up Your Feet Program (Kaiser Permanente)

  • Referral to English language courses and employment training (Healthy Homes)

  • Family Wellness Warriors Initiative – workshops and training for providers and residents on abuse and neglect treatment and prevention (Nuka)

  • Need for education identified via regular community meetings and referral to welfare agencies is facilitated (Embrace)
Employment/Working Conditions

  • Healthy Workplace and HealthWorks wellness programs for employees (Kaiser Permanente)

  • Referral to welfare agencies re: employment by case manager (Embrace)

  • Employment training (Healthy Homes)

  • Need for employment identified via regular community meetings and referral to welfare agencies is facilitated (Embrace)
Social Environments

  • Focus on socializing to help keep elderly active, fit and healthy in their social environments (KAPI)

  • Primary care centre used as a meeting place and community hub (Nuka)

  • Social case management and/or referrals to welfare agencies (social workers or case managers support patients with complex social problems) (Gesundes Kinzigtal, Embrace)

  • Fostering of “working together” with the Alaska Native community for governance, planning and delivery of different types of care (Nuka)

  • Physical exercise through social networking – KP Walks and Every Body Walk programs (Kaiser Permanente)

  • Integrated system of community-based care, offering front and second-line health and social services, incl. short- and long-term care in community and institutions (SIPA)

  • Single point of contact in each zone (health and social care co-ordinators) (Torbay)

  • Family Wellness Warriors Initiative – weekly support groups and gatherings for victims of abuse and neglect (Nuka)

  • Regular community meetings to facilitate referral to welfare agencies (Embrace)

  • Community engagement via locality-based advisory groups, governance, surveys, focus groups, telephone hotlines, reinforcement of “working together” attitude (Nuka)

  • Established regional organization, Social Care and Health District, for co-ordination and co-operation of health and social care organizations (Hartberg)
Physical Environments

  • Primary care centre used as a community hub was designed and built using traditional materials and exhibiting local arts to foster pride and confidence in local communities (Nuka)

  • Housing options advice, home improvements (Healthy Homes, Healthy Housing)

  • House modifications due to disability (Healthy Housing)

  • Re-housing due to overcrowding (Healthy Housing)

  • Placement in stable housing (Hennepin)

  • Monitoring of protocols, control of budgets to allow utilization of home services, group homes, and additional services (SIPA)

  • Co-location of health and social care teams (Torbay)

  • Co-location and “open concept” – all providers in one open space (Nuka)

  • Enhancing residents’ sense of identity, security and inclusion by involving householders in home renovations (Healthy Housing)

  • Primary care centre used as a community hub was designed and built using traditional materials and exhibiting local arts to foster pride and confidence in local communities (Nuka)
Personal Health Practices and Coping Skills

  • Health promotion workshops (Healthy Homes, Healthy Housing)

  • Health risks education (Healthy Housing)

  • Safe opportunities for physical activity (Spokane, Kaiser Permanente)

  • “Patient university” (health education and patient counselling by medical experts) (Gesundes Kinzigtal)

  • “Healthy body weight” combining prevention with regular blood sugar level check ups (Gesundes Kinzigtal)

  • Physical activity integrated into all aspects of daily life, activated employees and health care professions, marketing of what matters, healthy foods being available throughout the community, and schools strengthened as the heart of health (Kaiser Permanente)

  • Referral pathways supported by teams of referral, health, and social care coordinators and IT (Torbay)

  • Integrated medical care complimented by dental, behavioural, after-care, youth, elders; Family Wellness Warriors; Tribal and Traditional Services; Chiro, massage, acupuncture (Nuka)

  • Integrated approach with physical activity integrated into all aspects of daily life, activated employees and health care professions, marketing of what matters, healthy foods being available in the community, and schools strengthened as the heart of health (Kaiser Permanente)

  • Self-management support and prevention for frail and complex care needs via community meetings and case manager (Embrace, Nuka)

  • Health and fitness promotion for elderly with focus on socialisation (KAPI)

  • Traditional Healing Clinic for acute or chronic pain, behavioural health and counselling (Nuka)

  • Family Wellness Warriors Initiative – fostering individual/community skills to cope and respond to abuse and neglect and its prevention (Nuka)

  • Increasing access to healthy foods via community kitchens (Spokane, Kaiser Permanente)

  • Patients (customer-owners) and providers are encouraged to use phone, email and text for routine monitoring and some preventative screening (Nuka)

  • Patient-facing online tools for managing preventive and chronic care to increase patient agency in health promotion (Kaiser Permanente)

  • Patient self-management and shared decision-making (Gesundes Kinzigtal, Nuka, Kaiser Permanente, Jönköping)
Healthy Child Development

  • Child immunisations (Healthy Housing, Nuka)

  • Reducing child abuse and neglect (play and learn groups) (Spokane)

  • Pre- and post-natal care, including advising on birthing options and carrying out six-weekly check-ups as part of primary care services (Nuka)

  • Increasing access to first trimester prenatal care for marginalized women (Spokane)
Biology and Genetic Endowment No interventions noted
Health Services

  • Individual treatment plans and goal-setting agreements between doctor and patient (Gesundes Kinzigtal, Nuka, Kaiser Permanente)

  • Follow-up care and case management (Gesundes Kinzigtal, Nuka, Kaiser Permanente)

  • System-wide electronic patient records (Gesundes Kinzigtal, Nuka, Kaiser Permanente)

  • Intervention programme for patients with chronic heart failure (Gesundes Kinzigtal)

  • ‘Healthy body weight’ combining prevention with regular blood sugar level check ups (Gesundes Kinzigtal, Kaiser Permanente)

  • Referrals to paediatric and women’s clinics with coordination from primary care team (Nuka)

  • Healthy Homes on Prescription in primary care (Healthy Homes)

  • Healthy housing surgeries in primary care (Healthy Homes)

  • Multidisciplinary team working with all family members to enable behavioural change (Nuka)

  • General practitioner and nurse-led case management aim to address the emotional, psychological and social determinants of health (Nuka)

  • Health and self-management education for patients and families/caregivers (Jönköping, Kaiser Permanente)

  • Supplementing medical records with data from the corrections department, foster care system, housing providers, and other local agencies to identify those whose health may be at risk because of nonmedical issues (Hennepin Health)

  • Stratification into (A) no complex care needs and with low frailty level; (B) frail at risk of complex care needs; and (C) complex care needs (Embrace)

  • Stratification into 1) children and young people, 2) people with mental health conditions, 3) people with drug and alcohol addiction, 4) older people (Jönköping)

  • Population risk stratification based on Kaiser’s Know your population model (Torbay) or simple assessment scales (NWL; Hennepin)

  • Patient panel from registered list of patients (Nuka, Kaiser Permanente)

  • “Esther model” and “Mrs Smith” provided basis for designing care pathways for all older people (Jönköping, Torbay)

  • Informal/formal multidisciplinary teams coordinate & provide care (Torbay, Embrace)

  • Community-based multidisciplinary teams responsible for health and social services and coordinating hospital and nursing home care (SIPA, Hartberg)

  • Inter- and multi-disciplinary group meetings to develop unified view of patients’ care and system navigation (NWL, Embrace, Nuka, Kaiser Permanente, Jönköping)

  • Case managers for medical and social issues, liaising with physicians, and following patients throughout care trajectory, assuring continuity and easing transitions between hospital and community (SIPA, Nuka)

  • Integrated system of community-based care, offering front and second-line health and social services, incl. short- and long-term care in community (SIPA)

  • Whole-system approach, with hospitals, primary health care and other community services in partnership with zones (Torbay)

  • Mental health services integrated using a ‘hub and spoke’ model (Torbay)

  • Integrated medical services (primary care, women’s health, paediatrics, optometry, urgent care) complimented by dental, behavioural health, family wellness, tribal and traditional services, chiro, massage, acupuncture

  • “The Esther model” –network of health and social care organizations; redesign of intake and care transfer process across the continuum of care; team-based telephone consultation (Jönköping)

  • Increasing access to first trimester prenatal care for marginalized women (Spokane)

  • “Esther model” provided basis for designing care pathways for all older people (Jönköping)

  • Monitoring of interdisciplinary protocols (nutrition, falls, congestive heart failure, dementia, depression, medication, vaccination) (SIPA)

  • Outreach conducted centrally at region and at medical centers via telephone, secure messaging, mail (Kaiser Permanente)

  • Social worker goes on rounds with a local nonprofit’s street outreach team to find homeless members (Hennepin Health)

  • Established regional organization, Social Care and Health District, for co-ordination and co-operation of health and social care organizations (Hartberg)

  • Established primary care trust to commission community health and social care services (Torbay)

  • Developed integrated management structure for primary care trust and adult social services (Torbay)

  • Established single management system (Torbay)

  • Established IT tool to bring together medical and social care records from different provider organizations in one location (NWL)

  • Making and sustaining large-scale changes to create an integrated care system capable of improvement (Jönköping)

  • Complete care with panel management and regional safety nets to identify and respond to the needs of patients (Kaiser Permanente)
Gender No gender-specific interventions noted with the exception of interventions for marginalized expectant mothers as part of the Spokane and Clark counties Maternal and Child Health Inequities initiative
Culture

  • Providers acknowledge and incorporate importance of culture to well-being (Healthy Housing)

  • Engagement of tribal elders and the Alaska Native community in design and delivery of care (Nuka)

  • Traditional healing provided by tribal doctors whose skills are culturally relevant (Nuka)

  • Governance from Alaska Native community (Nuka)