The continued realization that place matters has led to the emergence of the field of population health, which includes health determinants, health outcomes, and links between the two. The Robert Graham Center, the policy arm of the American Academy of Family Physicians, recently hosted a forum focused on population health, with experts from New Mexico and North Carolina offering their perspectives on how to address the social determinants of health. Dr. Arthur Kaufman, the vice chancellor for community health at the University of New Mexico Health Sciences in Albuquerque, discussed how practices in New Mexico’s university system are beginning to take note of the importance of social determinants that are often ignored, such as low education or poor living conditions. Kaufman also mentioned the critical role of community health workers in helping physicians reach and assist community members dealing with financial or social issues. Dr. L. Allen Dobson, Jr., president and CEO of Community Care of North Carolina (CCNC), described how CCNC is linking their data with real-time pharmaceutical data to create risk scores for patients. Dobson noted how these data have been essential for reducing hospital admissions and readmissions by allowing physicians to reach patients before patients reach the hospital. See future Primary Care Forum topics.
Issues remain, however, as to what determinants and outcomes are most important to measure, as well as the availability of these data at relevant geographies. In response to this, the Centers for Disease Control and Prevention (CDC) created a resource guide of the most frequently recommended health outcomes and determinants, the Community Health Assessment for Population Health Improvement. The guide breaks down the data into two domains, Health Outcomes and Health Determinants, and then separates dozens of indicators into several categories, including Mortality, Morbidity, Health Care, Health Behaviors, Demographics, Social Environment, and Physical Activity.
Using this guide as a framework, HealthLandscape created the Population Health Mapper which includes the majority of the Health Outcome and Health Determinant Metrics identified in the report at the county level.
The Population Health Mapper allows users to select metrics from the seven categories and use a slider bar to set thresholds. By default, thresholds are set at values that represent national benchmarks. The tool will highlight those counties that are outside of the national benchmark, or will incrementally shade or remove counties depending on how the user modifies the thresholds for selected indicators. Darker gradations of color will indicate which counties are outside of the established thresholds for multiple indicators. Users can also view a histogram that shows the number of counties outside of thresholds by the number of indicators, allowing users to quickly filter by the number of indicators that are outside of the established thresholds.
You can use the Population Health Mapper at:
To learn more about the Population Health Mapper, join one of regular webinars at
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