Why is Community Population Health Improvement So Challenging?

Jason Gilder, Ph.D.

I am now firmly in the third week of my three-week adventure with the IBM Health Corps team in Durham, NC. We are partnering with Duke Health to build out a strategy to improve the health of the community, with the community. That last piece is crucial to building the trust of the community members and the many organizations already working hard to deliver healthcare and health-related services across the community. We have met with several community organizations that are directly involved with delivering health services, referring individuals to health service providers, care management services (such as assisting patients with managing their mental health visits), providing ancillary services (such as medication assistance around getting access to affordable medications), providing goods related to wellness (such as cell phones to stay in touch with a care manager or provider diapers for new mothers), and educational services to keep the public informed (such as HIV awareness around free testing and a pill that can help avoid contracting the disease).


With so much effort across the community, why is population health improvement such a challenge? Why does Durham County lag on certain health outcomes, even with Duke Health in their backyard, a top healthcare system? Clearly, many organizations are working to address the population’s needs. These same groups will also be the first to lay out the challenges of delivering care in the community. As with many issues in healthcare, it usually comes down to people, process, and politics.


Sometimes the biggest challenge in addressing an individual’s need is simply finding the organization or program that can best help them. Groups like United Way 211 and the Durham Network of Care work to catalog the many organizations, programs, and services that exist in the community. However, the task is a never-ending investment. Organizations change addresses and phone numbers, organizations close their doors, and new organizations and programs are created on a regular basis.


Many community organizations are not fully aware of what other organizations are doing. Even when one organization is aware of another, they typically aren’t fully aware of the other organization’s capabilities or quality. This lack of visibility can lead to uncertainty and distrust and prevent individuals from being referred to those organizations and services.


Funding is typically the primary challenge of most community based organizations. Grants are limited and the needs are great. Community organizations often compete for the same set of funding. Organizations can further compete around offering the same services as another, presenting competitive messaging around their services, and their approach of recruiting patients for services – all which can help justify their next round of grant funding.


Successful population improvement efforts require the right information at the right time. However, information sharing rarely takes place between organizations. An organization dealing with diabetes management may not be aware of an individual’s ability to obtain nutritious food. A patient seen in the hospital may not have information around his or her housing environment and ability to care for himself after discharge. The disconnect can result in siloed care efforts where no single organization possesses a complete view of the patient’s condition and their social determinants of health.


None of the listed challenges mentioned a broken system, only one that can be improved with better coordination and collaboration.

Coordination Across Services

Individuals in need typically require multiple services. Organizations that are tightly coordinated can track referrals to ensure that an individual is enrolled in the program he or she needs. A patient in the hospital who has an issue with adequate housing can be referred to the right affordable housing program. The patient’s care manager can be informed when the patient has been enrolled and placed in a better home.

Collaboration Around Programs

Most community organizations have established goals for their own programs. However, community population health improvement efforts would likely be more successful if care management programs were jointly created across multiple organizations. Tackling diabetes and nutrition could involve a diabetes management group and a food access organization building out a common care program together.

Collaboration Around Funding

Collaboration across organizations extend beyond joint programs. There are opportunities for organizations to work together on joint grant opportunities. There are situations where a program may appear to be losing money in one area while driving overall savings around an individual’s care. Funding for such programs is often cut. Collaboration across organizations will allow for better tracking of overall program effectiveness, return on investment (ROI), and opportunities for better funding.

Collaboration Around Staffing

Typically, the second biggest need of an organization is adequate staffing. There are opportunities for organizations to partner around sharing resources. Individuals working in one organization can work in a partner organization as a “borrowed resource” when demand is high or when a specialized resource is needed, like a mental health professional.

Collaboration Around Data Sharing

Understanding the full view of an individual and their outcomes is often improved by sharing information between organizations. While legal and compliance hurdles can be problematic, they are not impossible. Proper data use agreements (DUAs) and business associate agreements (BAAs) often allow for data sharing to enable more complete patient management.

Collaboration Around Measuring Outcomes

Understanding true outcomes for a population are greatly enhanced with the collaboration of multiple organizations. Joint quality metrics across organizations can help track the population’s journey through the system to understand which areas are working and which need additional focus. That feedback loop is essential to improving our system of care.

Collaboration With The Community

Population health improvement efforts require the community’s active participation to be successful. The best way of getting community investment is through transparency and feedback. It should be clear what services are being offered, how quality is being measured, and what impact is being observed in the community. Community members should have an opportunity to take a role in shaping the programs and goals to ensure that the overall needs are being met.

These combined health improvement efforts introduce the opportunity to address true community population health. Once you understand the state of health of a community, you can introduce additional programs on social determinants of health to help drive community-based health improvement at a larger scale. Leveraging additional data sources, such as bus routes, bike trails, pollution levels, socioeconomic status, food pantries, parks, and program benefit coverage areas allow for a macro view of the community. This view then allows for more effective planning around what programs, services, and opportunities should exist for individuals and where they will make the greatest impact on the community. The future blueprint of the community forms a community health care plan and can be tracked and managed in a similar manner as traditional population health programs. A community care management program can establish quality metrics to track process and outcome metrics across neighborhoods to understand which areas are improving and which require greater focus and attention.

None of the opportunities here require a drastic redesign of the care delivery system or millions of dollars in infrastructure or software. However, it does take a concerted effort to align priorities and involvement across care delivery stakeholders, community partners, and the citizens themselves. Many components of these improvement efforts are already underway in Durham County and elsewhere across the US. It is important to identify which pockets of activity are working well to serve as a guide for others moving forward. Population health improvement does not need to be a big bang. Improvement efforts can be rolled out in phases to increase trust and collaboration across a community over time. However, it is crucial to continually maintain, expand, and refine improvement efforts so that health delivery stakeholders and the community remain engaged in the process and to ensure that the momentum of driving improved health outcomes is not lost.

Jason Gilder, Ph.D. is currently the Senior Director of Analytics and Informatics at IBM Watson Health Cleveland.  Jason has supported the design and development of population health and healthcare research solutions within Watson Health.  He manages an Innovations team that develops the strategy around the management and use of healthcare data and analytics to drive improved patient care and management as well as helping enable researchers to discover new insights.  Jason decided to pursue engineering at the age of 9 when his grandfather told him about his career as an engineer at IBM. 




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