Overview

 Background

The New York Academy of Medicine Primary Care and Population Health Working Group comprises representatives from academia, New York City and State health departments, payors, community health centers, and major hospital systems. The Working Group’s mission is to ensure that population health is central to the implementation of health care reform, with a special focus on urban communities.

Among the high-priority obstacles to greater collaboration between clinical and public health entities identified by the Working Group is the lack of an organizing framework for achieving mutually-valued population health goals. To this end, the PCPH Working Group set out to create a "Metrics Matrix" of evidence-based interventions employable across a spectrum of clinical- and community-based actors, and oriented around a set of high-priority population-based metrics.

In reviewing metrics, we evaluated multiple priority-setting agendas at the local, state, and national levels. We prioritized metrics that would be ambitious yet realistic for a broad range of community stakeholders, as well as those that articulated the most specific benchmarks. Almost all of the metrics utilized apply to total populations in a geographic area, rather than populations in care or subpopulations with already-diagnosed disease. In each case, the metrics proposed by New York City and New York State most explicitly met these organizing criteria and thus were used as the foundation for the matrix.

We also sought to separate out and elevate any metrics that specifically addressed the elimination of health disparities, which are pulled out and displayed separately in the bottom left of each figure. It should be emphasized that there was a notable lack of clear and specific metrics focused on health disparities to consider among national agendas.

 Metric Sources Reviewed

• New York State Prevention Agenda
• Take Care New York
• National Quality Forum
• National Prevention Strategy
• HHS Action Plan to Reduce Racial and Ethnic Health Disparities
• National Stakeholder Strategy for Achieving Health Equity

In our review of interventions, we considered both clinical and non-clinical approaches, with the highest priority reserved for interventions with the strongest supportive evidence base. Our intention was not to create an exhaustive database, but rather to propose a framework to build upon and to provoke conversation about how to create a collaborative and multi-disciplinary population health system.

 Intervention Recommendation Sets Reviewed

• CDC Community Guide
• U.S. Preventive Services Task Force
• Mobilizing Action Toward Community Health
• NYAM Compendium of Proven Community-Based Prevention Programs

Using the Take Care New York and New York State Prevention Agenda as foundational sources, a set of 11 metric domains was used to scaffold the matrix. These 11 domains were cross-checked with other priority-setting agendas—such as the National Prevention Strategy—and were demonstrated to be a "superset" of the domains used by other efforts. The accompanying literature survey conducted by the Working Group also informed the selection of these domains.

 Domains

1. Tobacco
2. Chronic Disease Management
3. Access to Quality Health Care
4. Promote Physical Activity and Health Eating
5. Infectious Diseases
6. Mental Health
7. Alcohol and Substance Abuse
8. Cancer
9. Maternal and Child Health
10. Healthy Environment
11. Unintentional Injuries

Finally, interventions were stratified according to which actor in the health system bears primary responsibility for implementation. While some interventions are irreducibly cross-cutting across actors, it was attempted to assign primary responsibility where possible. Definitions for the various groups of actors were drawn from the literature and previous analyses as described below.

 Actors

Clinician: any health care provider who is accountable for addressing a large majority of personal care needs, developing a sustained partnership with patients, and practicing in the context of family and community (Institute of Medicine, Defining Primary Care, 1994)

Patient-Centered Medical Home: a health care setting for providing comprehensive primary care by facilitating partnerships between individual patients, their personal physicians, and the patient's family (Patient-Centered Primary Care Collaborative, 2007)

Community Partners: groups that collaborate due to affiliation by geographic proximity, special interests, or similar situations with respect to issues affecting their well-being (Centers for Disease Control and Prevention, Principles of Community Engagement, 1997, also Figure below)

Government: local, state, and national agencies dedicated to public health or health care delivery, as well as activities of other agencies affecting broader determinants of health (e.g. housing, transportation, education, economic development etc.)

Payors: public and private sources of funding for health care delivery and public health interventions (note that payors’ practices regarding covered services are not specifically included)

Institute of Medicine, The Future of the Public's Health in the 21st Century, 2002.