What is Population Health?

Patient- or client-centered care delivered by prepared, proactive practice teams is essential for excellent healthcare delivery (Center for Accelerating Care Transformation). Community Health Workers (CHWs) are important members of healthcare teams, bridging gaps between clinical health care and community-based resources (Center for Health Care Strategies, 2025).

In healthcare, we often talk about the Quintuple Aim, a framework developed by the Institute for Healthcare Improvement (2025) to understand and improve health system performance. The Triple Aim (the initial form of the Quintuiple Aim) was proposed by the Institute for Healthcare Improvement (IHI, 2012) as a purpose statement for simultaneously improving population health, patient experience, and per capita cost reduction. The Triple Aim was adopted by the US Department of Health and Human Services as a framework for the National Quality Strategy, the Centers for Disease Control and Prevention, and the Commonwealth Fund. The Quintuple Aim expanded the Triple Aim beyond quality and cost to include human and equity dimensions of care: population health, patient experience, cost, provider well-being, and health equity.

Over the next several months, we will explore each of these dimensions and how CHWs contribute to improved outcomes.

The first dimension we will address is population health.

What is population health?

There is ongoing confusion about the difference between population health and public health. These terms are often used interchangeably, but they are separate yet related disciplines. The World Health Organization (2023) describes public health as aiming “to provide maximum benefit for the largest number of people.” Public health agencies are organized at local, regional, state, and federal levels with responsibilities for communicable disease control, chronic disease and injury prevention, environmental health, emergency preparedness, assessment and surveillance, community partnership development, and policy development (Kaiser Family Foundation, 2025).

The term population health initially surfaced in 1990 with a focus on health status and outcomes in specific groups of people (D. Kindig & G. Stoddart, 2003). Groups may be comprised of patients based on location, provider practice, payer, chronic condition(s), age, health behaviors (e.g., cancer screening, emergency department use), or other variables. The goal of population health is to proactively identify and implement interventions to optimize health status within a group. This is done by implementing targeted, evidence-based interventions that often go beyond physical and behavioral health care to address social, economic, and environmental factors impacting health.

What is the community health worker’s role in population health?

CHWs play an important role in population health, particularly with increased recognition of Social Determinants/Drivers of Health (SDOH). CHWs bring lived experience and cultural responsiveness needed to build trusting relationships with patients and families (CHCS, 2025).

They are educated in SDOH assessment and evidence-based approaches such as motivational interviewing, goal setting, and action planning. CHWs have a deep understanding of community-based services and assist clients, families, and caregivers with navigating complex healthcare systems.

CHWs provide outreach, education, and social support for issues such as unstable housing, food insecurity, and transportation. CHWs may also support patients with chronic health conditions such as diabetes by reinforcing the importance of medication adherence, monitoring, and follow-up (CHCS, 2025).

The Practice Transformation Institute (PTI) CHW educational programs strengthen CHW knowledge, performance, and contribution to improved health outcomes. PTI is an approved provider of Community Health Worker (CHW) training by the Michigan Department of Health & Human Services (MDHHS). The approval follows a rigorous application process and more than two years of PTI providing CHW training through community and health system partnerships and support. Among one of the CHW training programs approved by the state, PTI is the only organization with the coveted IACET* accreditation.

The program teaches the National C3 Council skills and health knowledge necessary to function as a CHW in a variety of community settings. This robust training offers teaching excellence along with a leading-edge curriculum that supports the participants in achieving the learning objectives of the program.

For more information on PTI CHW training, visit https://transformcoach.org/learning-solutions/community-health-worker-chw-program/ or call (248) 475-4736.

References:

Center for Accelerating Care Transformation, https://www.act-center.org/application/files/1616/3511/6445/Model_Chronic_Care.pdf

Institute for Healthcare Improvement, https://www.ihi.org/library/topics/quintuple-aim

Kindig, D. & Stoddart, G., (2003, seminal article). American Journal of Public Health, 93, 380-383.

Michaud, J., Kates, J., Oum, S., & Rouw, A., U.S. Public Health 101. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-u-s-public-health (accessed 11-5-2025).

Roux, A.V. (2016). On the distinction – or lack of distinction – between population health and public health. American Journal of Public Health, 106(4), 619-62. Doi: 10.2105/AJPH.206.303097. PMID: 26959262. PMCID: PMC4816152.