Primary care physicians involved in population health initiatives will be required to think strategically about the best way they can benefit from partnerships with organizations that span multiple sectors to create a holistic approach to the health and well-being of populations of patients.
Increasingly, physicians are collaborating with other providers, hospitals, community health facilities, accountable care organizations (ACOs) and housing and education departments. These relationships are forcing discussions about the level of investments that should be committed, the agreements that need to be evaluated and the adoption of policies that need to support these efforts.
In addition to capturing and analyzing clinical data, physicians who embrace population health’s approach to care need to collect more information and pay closer attention to social determinants that have a bearing on the health of large groups of patients.
Factors impacting patient health that exist outside of a doctor’s control, such as transportation to and from appointments, the management of a nursing home or patients’ accessibility to fresh healthy foods are important considerations. This is especially true as doctors operate under a value-based system that requires them to meet clinical quality metrics to receive incentive payments.