Determine Common Goals and Metrics

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Progress on population health requires a shared goal that is specific enough to be measured. Goals should be determined based on assessed needs, resources and feasibility, with input from multiple partners.

Health outcomes involve a complex set of factors, so it is important to include metrics inside and outside the healthcare system, and to measure progress on outside factors such as living conditions that can affect health. For these reasons, data sharing among partners is vital to getting the full picture of population health.


Challenge: Partners and stakeholders may have differing priorities, making it difficult to achieve consensus beyond broad, overarching goals.

Try: Select a goal that is specific enough to measure and one for which an early win is achievable. Include strategies and related metrics that simultaneously impact multiple goals. For example, reducing sugary beverage consumption impacts diabetes and pre-diabetes, obesity and oral health. Capitalize on early wins and use them to build momentum for long term goals.


Challenge: When specific metrics are incentivized (i.e. MCO contracts), partners whose work is not as closely connected with those metrics need reassurance that their priorities are still important.

Try: Identify connections between activities that address the incentivized metric and other priorities. For example, depression management strategies reduce risk of substance use disorder and adverse childhood experiences.


Challenge: Accountability for a discrete patient population may not adequately address an urgency within a population, and/or a larger geographical population. This can impact both immediate and long-term outcomes and has special implications for health equity.

Try: Use disparities sensitive data as much as possible and identify strategies that can be tailored for populations. Create plans that begin with a patient population and takes steps to include more of the population base over time. Document and report any unintended negative consequences that affect a vulnerable or disparate population or community.