Identify Populations of Concern

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A population health approach is designed to address a health issue in a given population. Populations may be defined by shared characteristics or health concerns (i.e. all patients with diabetes; Medicaid patients with diabetes; patients 55 and older with diabetes.)

By beginning with interventions in a clinical setting for a defined patient population, and expanding to include community linkage and total population strategies, we can systematically work toward total population health. The key is to clearly define the population of concern before implementing strategies, so that outcomes can be measured for those populations.


Challenge: Health care providers are focused on practice transformation with their patient population. They may not have time and resources to also focus on total population health.

Try: Build bridges between health care and community services by supporting home visiting, mobile health care in schools and worksites, and community health workers. Enlist provider help in ways that are not time consuming; for example, signing a letter of support for a health-related policy.


Challenge: It can be tough to develop strategies that serve a geographically defined region and still take into consideration subpopulations that have unique characteristics and needs.

Try: Ask your local health jurisdiction for help identifying subpopulations in your region, and connect with community organizations and nonprofit agencies for ideas on how best to serve them. And as mentioned under Health Equity, go to the communities themselves; they are the experts.