Population Health Management: Why?

A conversation between Sollis and ForestVue Leadership


Martha Sylvia, CEO ForestVue Healthcare Solutions

Nigel Slone, CEO Sollis

We initially connected on our shared philosophy of the importance of an interdisciplinary team approach to Population Health Management (PHM) and analytics. Separated by the North Atlantic Ocean, yet unified in a shared vision for improving outcomes, quality and costs for the populations we serve; we offer here some thoughts on why a Population Health Management approach is the key to a reimagining of the delivery of health and care in the future.

For a large part of 2022, Nigel has been facilitating a number of different Places[1] as part of a NHS England (NHSE) sponsored Place Based Development Programme (PDP). He has been supporting on a module focused on Population Health Management (PHM) & Integrated Transformation.

For many years, Martha has been supporting organizations in the U.S. on their journey to value-based care.  She addresses the people, processes and culture that is needed to make the change from fee-for-service payment to payment that is based on outcomes achieved in populations.

That wicked Population Health Management question: Why?

A gnawing question eats away at the heart of both of our operations. That question is WHY?  WHY do this? WHO benefits? It’s a good question, which deserves an answer. We have tackled this question together in a thoughtful dialogue that we would like to share with you, our colleagues.


Equitable distribution of healthcare resources.

Because we assess populations and understand the health determinants that are impacting outcomes, we can better direct interventions to the needs of groups of patients with similar characteristics and need for healthcare resources. We know that medical care accounts for only 20% of healthcare outcomes with the other 80% of healthcare outcomes driven by social and behavioral determinants (SBDoH) of health.[2] A Population Health Management approach seeks to understand and ultimately address multiple determinants of health, delivered in a methodical, organized, and systematic fashion.

Better design of health and care interventions.

 Population Health Management strategies are at their heart data driven endeavors and through the data we seek an understanding of what factors are driving poor outcomes in a population or sub-population (cohort). When interventions are designed with an understanding of the drivers of those poor outcomes – based on evidence and not fairytale and hearsay – then we give ourselves the very best opportunity to transform services which can truly deliver optimized patient outcomes and experiences. In summary we give ourselves the very best chance of creating a better world for the patients and citizens we serve.

We can measure the impact. 

A population health approach is a systematic and standardized process. It is not something done as an add-on to the day job. It is the day job. The process includes a thorough and detailed population assessment and it is through this stage that we acquire an understanding of where the opportunities exist to create better patient outcomes and experiences.

We should know the measures that we need to impact when we design and implement interventions This means that at the implementation stage of the intervention, we can measure its processes to ensure that the intervention is being implemented as planned. More importantly, we can monitor outcomes from the onset because they are already defined.  This is satisfying for all stakeholders.  Care providers love to know that they have had an impact. Even better when it’s in aggregates of patients in addition to one-at-a-time.

Better care pathways and reduced variation.

Without a population approach where we segment populations based on patients with similar healthcare needs; care providers are left to follow their instincts and do what has worked best for them in the past. They need to each do their own evidence review and independently try to implement that evidence. With a population approach, care pathways and interventions are in place and care providers have a roadmap for patients based on well thought through segmentation methodologies and a nuanced understanding of the risk in those populations.   What we seek to create are evidence-based pathways (e.g.  for patients with complex multimorbidity or other segments) that can be used to direct care. Care delivery is potentially much more efficient and care providers get feedback through analytics on these pathways to understand what is working (and what is not) and how these pathways are impacting patient outcomes.


Population Health Management is a team sport. 

 There is a role for everyone on the Population Health Management team when taking a population health approach.  In a well-designed Population Health Management  program, everyone knows their contribution, and everyone understands the  value they bring to the improvement of health outcomes. This is motivating to the many and varied stakeholders that will constitute a well-designed Population Health Management team.  Patients are getting the best care possible, and they reap the benefits of interactions with a motivated, inspired and committed delivery team.


Before embarking on a Population Health Management program, it is necessary to start from the “Why?”

In this blog we have sought to provide answers answer to that Why and in so doing provide compelling reasons why we believe Population Health Management offers the potential to improve patient outcomes and patient experiences.

There are no short cuts here. Well designed Population Health Management programs require commitment and engagement from a wide group of different stakeholders, many of whom are being asked to work in completely different ways to those which they become accustomed.  For many there will be feelings of anxiety and unease. What is required is a cultural shift.

Success is dependent on the adoption of a guiding framework and set of systematic processes. This framework is clearly articulated in the Population Health Analytics handbook[3] authored by Martha Sylvia and Ines Maria Vigil.

Follow this process and you will give yourselves the very best chance to identify opportunities for improvement for the populations you serve. The process and the framework provide a road map for success; where success is measured in the transformation of health and care services that deliver a better future for those in most need.

Start small but dream big. You have the power to change lives.



Martha Sylvia

Nigel Slone

10th October 2022

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[1] Places typically serve populations of between 250-500k. Typically they operate at a borough/council level.

[2] Source: University of Wisconsin Population Health Institute. County Health Rankings 2013. Accessible at www.CountyHealthRankings.org

[3] Sylvia, M., Vigil, I.M. (2022). Population Health Analytics. Jones and Bartlett Learning. https://www.jblearning.com/catalog/productdetails/9781284182477