Population Health Framework
Understanding the full context of health and well-being.
Imagine standing in an art gallery, appreciating a single brushstroke. On its own, you can evaluate the use of colour and texture, maybe identify the paintbrush that made that single mark — but take a step back. Now you can see the whole painting. Even further back, you view the painting in context within the gallery. Now it tells a story. It’s the same way with health.
When you look at only one outcome, a patient's presenting illness, for example, you have no way to understand the full context of their health, what is making them sick and the best way to help them. A holistic approach considers every aspect of that patient's life, including each unique circumstance, barrier, and struggle, to create a lasting, effective shift in their overall wellness.
What is population health? 
Alberta Health Services was asked by the ministry of Alberta Health to adopt a population health approach during primary health care service planning. Dr. Mary Modayil, Epidemiologist and Population Health Needs Framework lead, explains what they discovered and what was important to focus on:
- what is population health,
- why it matters to our wellness and,
- how to take a population health approach when service planning.”
"When examining population health and how to apply it in Alberta, the opportunity came to develop a framework to support health service planning. We engaged AHS portfolios across the entire continuum from acute care all the way to continuing care and everything in between, and what we learned quickly was that people are very passionate about this work (population health), but we aren’t implementing much of it in health care. So, the question became less about defining the what, or even how important it is, and really focusing on the how.”
The Population Health Needs Framework
“We propose that the definition be: the health outcomes of a group of individuals, including the distribution of such outcomes within the group, and we argue that the field of population health includes health outcomes, patterns of health determinants, and policies and interventions that link these two.” (Kindig & Stoddart, 2003)
“What’s come out of the RIFS (Reducing the Impact of Financial Strain) work,” says Lisa Kemp (Manager, Primary Care Network), “was when you apply a poverty screening tool or you ask the question ‘what matters to you’ — rather than ‘what’s the matter with you’— the physician and other teams, maybe social work and RNs, found they opened a can of worms and were left wondering how to address it because this is so much bigger than us. Some of the health issues are outside our mandate, but they’re still a part of whole health. And so, organically, in a grassroots way, some people were saying, ‘let’s form a coalition that involves people from healthcare and the community’… We need a framework or a vehicle to help us achieve this.”
By creating a framework to analyze, evaluate and act on the health needs of our population or communities, health outcomes can be improved for all Albertans. The Population Health Needs Framework is universal and can be utilized in any community to examine the context of that population. It provides the shared language and understanding needed for multiple health care service providers, practitioners and care teams to work together across many disciplines and hierarchies. In addition, the User’s Guide provides tools and activities to support the population health approach, starting with understanding the mental models of partners, understanding information sources, and co-designing services.
“Fundamentally, the framework is meant for partnerships to form, or support existing partnerships across the social, community, and traditional healthcare organizations. It is not meant to be applied to only one of those organizations. Community partners and community service organizations are meant to be at the table alongside traditional healthcare organizations because we can’t really do it by ourselves. No single organization has the capacity to address the needs of our communities.” Dr. Modayil
Although the framework can be applied and adapted by all populations, it is worth noting the specific and complex health needs of Indigenous communities in the province. Special care should be taken to unlearning biases and agendas and learning the specific cultural, historical and spiritual context of each Indigenous group. Having Elders and Indigenous organizations at the table during population health conversations is essential to success.
Start the Shift
The Population Health Needs Framework allows us to start the shift towards population health at every level of healthcare service planning. Implementation has taken place across three PCN clinics in the North Zone, where Lisa and Ping Mason-Lai (North Zone Project Manager) have begun to learn the struggles and triumphs of taking a population health approach.
“What’s the common goal? What’s the objective?” Asks Ping. “The language, understanding, and awareness is not consistent. That’s, I think, where some of the barriers are. For example, let’s say the ministry of transportation — they certainly don’t think of their issues as being health issues, but there's a huge impact for people coming out of healthcare, transporting to services, getting to appointments. I think the framework can help people understand the relationships and connections so we can solve some problems, whatever those common problems are.”
“What I often say is we need everybody at the table representing each area to be collectively wise; we’re only wise if we’re collectively wise,” Lisa intones. “The answers are in that collective accountable group. The solutions are found there.” She continues, “what we’re doing right now (in healthcare) isn’t sustainable. We need a model that’s sustainable and this framework allows for that sustainable model to provide better health services for our population.”
“I think the key for starting this work is to have an open heart, curious mind philosophy,” Ping supplies. “We have to get around the table, whoever it is, and listen, learn and ask questions. You have to build relationships first before any kind of implementation for this to work. We have to build relationships, then get to know each other, our strengths, opportunities, weaknesses, then start the work.”
The Population Health Needs Framework can guide how you plan and co-design health services with patients, families, and communities.
#StartTheShift
Population Health Needs Framework User Guide
