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Population Health at Essential Hospitals: A Road Map to Community-Integrated Health Care

Social, economic, and environmental factors can influence the health of individuals as much as the clinical care they receive or their behavior. This fact challenges health care providers to think more broadly about their role in communities, how they deliver care, and how they distribute resources.

Curbing social risk factors and the social determinants of poor health at the population level could provide the key to meeting this challenge while reducing health care costs and creating healthier communities.

For essential hospitals — those that fill a safety net role and face pressing resource constraints — a population health approach to care delivery represents an unprecedented opportunity to build a culture of health that benefits all. But they face uncertainty about resource requirements, a lack of nontraditional partnerships, and inexperience navigating the institutional culture shifts necessary for such work.

Essential Hospitals Institute aims to help hospitals overcome these challenges. With funding from the Robert Wood Johnson Foundation, the Institute developed a population health road map to guide hospitals and health systems toward population health improvement activities by meeting these operational objectives:


Each objective includes specific strategies and strategic steps, as well as illustrative examples from essential hospitals.

A detailed account of the Institute’s work, which included an environmental scan, a survey of America’s Essential Hospitals members, and key informant interviews with hospital executives and staff, can be found in the full report, Population Health at Essential Hospitals – Findings from Moving to Action for Hospitals and Population Health.

The Institute would like to thank the project’s technical expert panel for all of their contributions:

Rich Bell Active Living by Design
Karen Hacker Alleghany County Health Department
Leon Haley Grady Hospital/ Emory School of Medicine
Denise Koo Center for Disease Control & Prevention
Phyllis D. Meadows Kresge Foundation
Karen Minyard Georgia Health Policy Center
Greg Paulson Trenton Healthcare Team
Mary Pittman Public Health Institute
Jon L. Pryor Hennepin County Medical Center
Shannon Sale Grady Health System
Nishant Shah Contra Costa Health



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