The Division of Public Health Adopts New Population Health Approach

Introduction

The Delaware Division of Public Health (DPH) has worked to improve the health of the state’s residents both on an individual level, and as a whole at the population level, for many years. Most recently, DPH adopted a new strategic approach to how it addresses population health specifically. Over the last two to three years, DPH began to foundationally reorganize and intentionally connect staff with organizations and communities that are also working toward addressing population health issues. To further the Division’s efforts and lay additional groundwork, DPH formed a small working group in 2018 to discuss and solidify a population health plan.

The working group agreed that DPH staff needed to adopt common language. The group researched and reviewed various definitions for common terms such as health, population health, health equity, and social determinants of health and ultimately agreed on the following definitions:

• Health – The state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.¹

• Population Health – The health outcomes of a group of individuals, including the distribution of such outcomes within the group. Population health includes the interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations.²

• Health Equity - Achieving the conditions in which all people have the opportunity to reach their health potential; the highest level of health for all people.³

• Social Determinants of Health - The circumstances in which people are born, grow, live, work, and age, as well as the systems put in place that influence health. The underlying environmental, economic, social, and political structures that determine the quality and distribution of resources needed for health.³

Next, the working group determined an action framework that DPH staff could embrace at all levels and could use to guide the development of strategic intentional goals focusing on addressing specific population health issues. The group reviewed various concepts and settled on the Robert Woods Johnson Foundation (RWJF) Culture of Health Framework, which is a collaboration between the RWJF and RAND Corporation.⁴ The Robert Wood Johnson Foundation has committed itself to a vision of working alongside others to build a national Culture of Health (see Figure 1). The Culture of Health Action Framework sets a national agenda to improve population health, equity, and well-being. Informed by rigorous research on the multiple factors that affect health, it recognizes that there are many ways to build a Culture of Health, and provides numerous entry points for all types of organizations to get involved. The DPH team determined that the framework was an appropriate model to track progress in Delaware, in part because it encourages work across all sectors.

Figure 1.

– 10 Principles for a Culture of Health⁴

The RWJF Culture of Health Framework contains four action areas (see Figure 2). These action areas represent significant strategic opportunities to realize the culture of health at the community level. Each action area has drivers. The drivers are priority areas where attention and innovation are needed to make ongoing systemic, cultural, and social change that can impact health. Lastly, the framework provides measures (see Figure 3). DPH developed unique measures to track positive and negative changes in each action area over time.

Figure 2.

Culture of Health Taking Action⁴

Figure 3.

Culture of Health Framework⁴

In addition to adopting the Culture of Health Framework, the DPH team developed an internal strategy map (see Figure 4). This strategy map will guide day-to-day efforts towards improving specific population health issues. The DPH team incorporated the Culture of Health action areas into the strategy map. The strategy map will be used as a tool to guide the implementation of strategic initiatives, as well as to track internal efforts toward achieving identified population health goals.

Figure 4.

Division of Public Health Population Health Strategy Map

The DPH Population Health Plan and Strategy Map was shared with the DPH Leadership Team to obtain feedback and gain approval for implementation. Using the Map as a guide, Leadership team members were asked to document Policy, Systems and Environmental (PSE) level strategies that their programs are either currently engaged in, or could potentially implement in the near future, that are believed to have a positive impact on specific population health indicators. PSE change approaches seek to go beyond programming and into the systems that create the structures in which we work, live, and play. An effective PSE approach should seek to reach populations and uncover strategies for impact that are sustainable. Efforts may accelerate the adoption or implementation of effective interventions by effectively integrating approaches into existing infrastructures. Such approaches often involve the input of advocates, decision makers, and policy makers.⁵

As DPH works internally, using the strategy map to track its efforts, it is also employing continuous quality improvement review to help determine if its efforts have positive impacts. The Division has also embarked on a path to provide more information to the public regarding population health and the factors that impact health outcomes. To that end, DPH is developing a State of Delaware Population Health Indicators Scorecard (see Figure 5). The scorecard will provide more timely trend data for various clinical, social, and environmental data points. This scorecard contains measures across nine areas: community safety, healthy lifestyles, infectious diseases, maternal and child health, health services utilization, chronic disease, mental health and substance use disorder, economy, and education.

Figure 5.

Population Health Scorecard Measures, Division of Public Health, 2018

The DPH population health strategy also supports, and aligns with, State Health Improvement Plan (SHIP) goals. The population health scorecard will highlight and inform the public regarding how Delaware is trending on important indicators that impact SHIP goals. The division’s internal population health strategy work is designed to create alignment throughout programs that will allow DPH to evaluate current investments being made and make determinations as to whether current strategies are working or if a shift in investments would better support SHIP goals.

By following these data points and intentionally working to improve the clinical, social, and environmental health determinants, DPH and others can work collectively toward improving the state’s population health.