Identify Populations of Focus

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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. For example: all patients with diabetes; Medicaid patients with diabetes; patients 55 and older with diabetes.

Looking at your assessment, what health issues stand out? Which population groups show disproportionate health outcomes? Are there specific groups that experience disproportionate barriers to health and wellness? Partners can focus on these groups, and tailor strategies to achieve better outcomes.

When a population of focus is identified before strategies are implemented, outcomes can then be measured specific to those populations.

The population as a whole can benefit when strategies include intensive efforts with a specific population, supported by community linkages and broad population-wide efforts.


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 specific populations 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.