The Promise of Community-Based Population Health

After six great years co-developing a comprehensive, community-based population health enterprise with Children’s Health in Dallas, I am returning to Roberts Health Solutions.

A funny thing happened at Children’s Health – on my way to building a Medicaid HMO, an ACO, and a clinically-integrated provider network, I spent time “meeting the neighbors” in Dallas, and patient families shared with me that while health insurance and medical care were certainly important and necessary, they were also insufficient in and of themselves.

Families wanted an integrated, community-based ecosystem that allowed them to exercise their own agency and access what they needed for their own family’s health and well-being from the worlds of health insurance, medical care and community services in a convenient and respectful way. In essence, families were looking for avenues to address what we call their medical and nonmedical (social, environmental and behavioral) determinants of health, but there was a disconnect between what they wanted and what we were providing.

After 30 years in healthcare delivery and health insurance, Dallas completely changed my perspective on health and well-being and my approach to leadership.

Leading population health indicators are positive from the work that followed – a 49% decline in ED visits caused by childhood asthma – measurable improvement in BMI – an estimated 70% of school-based telehealth visits resulting in avoided ED visits, the child staying in school and Mom/Dad staying at work – and even changes to the Dallas housing code designed to improve the home environment for children.

No single stakeholder in the community, or any single program by a healthcare provider, can be transformational by itself. It not only takes a village to accomplish raising our children, it takes a collaborative and coordinating village that respects and honors families’ roles in creating their own destiny.

As healthcare providers increasingly assume financial responsibility for populations, the social determinants of health – if not effectively addressed – will continue to contribute to poor health and high medical costs.

A community-based population health management system can create tangible benefits for consumers, communities, healthcare stakeholders and community service agencies. I look forward to working with health insurers, healthcare providers and communities to create the formal alliances and structures needed to promote families’ health and well-being.