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BACKGROUND

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Population health is a term that reflects the health of patients across continuums of care with a goal of improving health outcomes. Its definition reflects the users’ relationship to that continuum: public health, advocacy and policy, research, or clinical care delivery. Public health has traditionally been focused on the safety and health of families and communities by preventing and treating diseases and injuries where children and their families live, learn, work, and play. Population health differs from public health in two main ways. First, it is dictated less by governmental health departments, and second, it is more inclusive of the healthcare delivery system. The focus of population health may span geography (eg, a region), a condition (eg, children with a chronic condition such as asthma), a payer (eg, patients in an accountable care organization or within a health plan), or any characteristic that would link accountability for outcomes for that group of patients. This gives rise to the concept of population management, where a common condition or other linking element may drive the practitioner to create and implement prevention or care strategies and promote health for groups of patients.

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Population health is defined as the art and science of preventing disease, prolonging life, and promoting health through recognized efforts and informed choices of society, organizations, public and private communities, and individuals. It encompasses a number of critical components for ensuring improved outcomes of care. Most importantly, it expands the reach (and the obligation) of the clinician from bedside care alone to a goal of ensuring the health of the patient, including helping the patient and family overcome barriers to access and coordinating care. Clinicians must also identify and mitigate the effects of social determinants of health and engage the patient and family in their own health management and disease and injury prevention. Social determinants may include education, economic stability, social and community context, and neighborhood and physical environments. The concepts of prevention and health promotion are not foreign to the pediatrician; however, population health introduces a great challenge for the provider to engage a great number of factors that influence health outcomes but are not within the locus of control of the clinician unless actively attempting to work in concert with other aspects of the healthcare system. Childhood obesity, asthma, and dental caries are not only prevalent in the US child population, but they have a reciprocal interaction with family dysfunction and school stress, necessitating that a provider address these social determinants in order to achieve improved outcomes of care. The Institute for Healthcare Improvement has described a composite model that best explains the interventions necessary to improve outcomes and thus quality of life. Prevention and health promotion include upstream factors in the patient and families’ environment (eg, physical or socioeconomic factors) that are further influenced by individual factors (eg, behavioral, spiritual, genetic factors). The practitioner must consider a broader array of determinants of health than is typical in ...

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