The Role of Nurses in Population Health Management

In 2016, the National Advisory Council on Nurse Education and Practice (NACNEP) called for changes in nursing education to better align with a new emphasis away from acute care and toward population health management.

Before exploring what that means for the nearly 3 million nurses in the United States, it is worth taking a moment to examine the relatively new concept of population health.

A standard definition of population health emerged from a 2003 report published in the American Journal of Public Health entitled, What is Population Health? In the report, authors David Kindig and Greg Stoddart defined population health as: “Health outcomes of a group of individuals, including the distribution of such outcomes within the group.”

This was the definition used by the NACNEP in its 2016 report, “Preparing Nurses for New Roles in Population Health Management.” While it has become the accepted definition of the term, the concept continues to evolve as the role of healthcare professionals is refined.

In 2015, the online publication Healthcare IT News sought clarity by asking 37 healthcare leaders to offer their personal definitions of population health. The definitions varied, but a consensus emerged around opportunities for health systems, agencies and organizations to work together for better health outcomes in their respective communities.

And that is where the idea of population health begins to be revealed as a practical concept for understanding and meeting the needs of patient communities throughout the nation.

The Population Health Cycle

The concept of population health represents a cycle that begins with the vast amount of health data that has become more accessible through electronic health records. That information is analyzed to develop risk assessment models for specific groups of people.

The risk assessment analyses are used to develop prevention techniques, and to determine best practices for treatment. The health outcomes that are derived from the prevention and treatment methods are then researched and combined with the existing data, which allows healthcare professionals to refine prevention and treatment techniques based on the improved data.

A number of questions arise along the way. According to Healthcare IT News, one of the most pressing questions is, “What is more relevant in the health outcomes of a population set, the behavior of its members or the actions of the healthcare provider?”

The answer to that question is being formulated even now as healthcare workers, especially those on the front line of care – nurses – are implementing population health management concepts into their approach to patient care.

Nurses and Population Health Management

According to the NACNEP report, the “jobs of many nurses are changing dramatically in the evolving healthcare system.” This is not news to nurses, whose responsibilities in recent years have increased and shifted in hospitals and other ambulatory care settings, as well as in research labs around the world.

This expansion and evolution of nursing responsibility, coupled with the fact that nurses represent the largest group of healthcare providers in the U.S., gives the nursing profession a tremendous amount of influence when it comes to the shift from a system that focuses on acute care to a system guided by the principles of population health.

Nurses are uniquely positioned to lead the effort to adapt the healthcare system to the changing needs of the many population groups in the U.S. According to the NACNEP report, nurses can:

  • Discover patterns across patient populations
  • Guide patients toward community resources and social services
  • Lead in the development of broad-based treatment and prevention methods

The NACNEP report further recommends a number of improvements to nursing curriculum in order to meet the requirements of a focus on population health. Nurse education, then, should enable nurses to:

  • Undertake population health initiatives
  • Support complex patient groups
  • Provide care coordination
  • Analyze population-level data from electronic health records and other sources
  • Optimize the use of research to promote evidence-based care

Much of the movement toward a population health model involves the use of digitally stored data becoming available with the shift from legacy record-keeping methods to electronic records.

HIMSS and Population Health

In February 2017, the annual conference for the Healthcare Information and Management Systems Society (HIMSS) in Orlando featured the organization’s effort to define and substantiate the role of nursing in the shift to the population health model.

The HIMSS report on population health management focused on the transition from fee-for-service payment to a value-based model, in keeping with new Medicare and Medicaid reimbursement rules enacted by the U.S. Congress. This transition emphasizes health outcomes, prevention and successful management of chronic conditions.

The HIMSS report also focused on the entire spectrum of healthcare – primary care, acute treatment, rehabilitation, long-term care and home care. It encouraged nurses to follow career paths that help them empower patients to take more control of their own healthcare, and to practice healthier behavior based on evidence-based methods.

Population health management nursing careers the HIMSS report highlighted included:

  • Health coaches
  • Care coordinators
  • Care navigators
  • Care managers

The HIMSS report also suggested that nurses, because of the nature of their work, are positioned to improve health outcomes by leveraging health informatics competencies, personalization analytics and patient-enabling technologies such as health mobile apps, wearables, telehealth and more. Nurses, in this role, are healthcare advocates as well as treatment providers.

Another area of the healthcare industry that is directly affected by the rise of population health management is nursing informatics. According to HIMSS, high-tech skills such as predictive analytics, data integration, clinical data management and other relatively new areas of expertise will be vital for the support of a population health management ecosystem.




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