We can define population health improvement as the practice of optimizing health and health care relative to cost for defined populations. For populations with multiple needs, the array of health supports may include health promotion services, prevention services, a wide range of clinical health care services, and a diverse array of enabling services such as education, social services, and transportation. Few if any clinical organizations have all of the capabilities necessary to provide all of these services on their own. Consequently, clinical-community linkages are essential for population health improvement.
We can see the results of clinical-community linkages in a variety of care models for specific populations. For example, the Chronic Care Model, the patient centered medical home, integrated care models, and care transitions models generally include clinical-community partnerships for optimizing care coordination and patient support in the home and community setting. In addition, schools, community-based organizations, and public health agencies play vital roles in providing health promotion and prevention services where people live, learn, and work. When these services are reinforced in the clinical setting, the impact is all the greater.
Given the importance of clinical and community services for improving health, it is logical to consider community collaboration as a core strategy for population health improvement. For practical purposes, community collaboration can begin with collaborative approaches to community health needs assessment, and continue with collaborative approaches for delivering services and supports. The key is to have a unifying strategy for convening and supporting community partners. We developed our community learning networks for just this purpose.