A Systemic Approach to Address Population Health, with a Focus on Underserved Communities

Background: Hospitals and public health agencies are increasingly asked to improve the health outcomes of underserved populations by addressing social determinants of health and long-term health goals, including those with chronic care conditions. There have been calls for systemic action and cross-sector collaboration to support these goals.

Methods: The paper uses research on service-dominant logic, inter-organizational dynamic capabilities (IDC), and social diagnosis to propose a four-step methodology: structuring the patient care journey into patient value networks, defining community model (CM) capabilities to support inter-sector collaboration, modeling the patient journey to understand challenges and competencies of patient populations, structuring a "meta-community model" (meta-CM) network to support patient transitions to address their long-term health goals.  The methodology is illustrated using three use cases of underserved populations.

Results: The paper illustrates the use of a three-level strategy (micro-, meso- and macro-level) to operationalize healthcare transformation using cross-sector collaboration to help patients reach their long-term goals. It highlights specific areas for future research and discusses the implication of how organizational leadership can build agility to their community strategy in a constantly evolving patient and technology environment.

Conclusions: The methodology proposed and illustrated using three different case scenarios highlights the need for community model actors to deepen their understanding of the life experiences of patient populations with both challenges and competencies and broaden their strategies using both a social and technology platform.