Adopting population health management in PHC. Bridging needs and response

Population health management can substantially contribute to realizing some of PHC's central attributes, including person-centeredness; accessibility; comprehensiveness; attention to health problems in their physical, mental, social, cultural and existential dimensions; continuity; coordination and community orientation. It can do this by supporting PHC providers in: • moving from a one-size-fits-all approach to targeted and tailored approaches that account for the needs of different groups within local catchment populations or population clusters with similar needs or health conditions; • moving from passive and reactive to proactive care, ensuring that people with different risks are identified and have their care anticipated; • moving from a narrow focus on clinical needs to a holistic approach focusing also on psychosocial needs and the social determinants of health; and • moving from fragmented and poorly coordinated care to better coordination and integration with secondary and tertiary care and partnership with other sectors and actors in the community. Although moving towards system-wide implementation of population health management requires several years of development work and takes time to achieve impact, population health management can promote improvements in PHC even before the full benefits of population health management are realized. Key and common success factors to enable population health management in PHC are described here as system (such as information governance arrangements that promote information sharing within and outside the health system, data stewardship capacity and skills or support of regulatory agencies); organizational (multidisciplinary and networked PHC models and integration and close collaboration with public health and social care agencies); and clinical-level factors (such as comprehensive and systematic data collection in PHC or patient and community engagement).