The Intersection of Research and Community Health: Using Evidence to Inform Population Health Strategy

Social determinants of health (SDoH) are the conditions in which people are born, grow, live, and work, and they significantly impact an individual’s health and wellbeing. With robust connections to community partners, access to data, and touch points with patients, healthcare systems are ideally positioned to address SDoH, yet systems struggle to identify how best to capture and manage SDoH needs. The hospital within our academic health system leveraged a partnership with our medical library to create an evidence review program, specifically aimed at informing the health system’s population health strategy and implementation tactics using best research evidence.
When tasked with developing a comprehensive population health strategy, the hospital within our academic medical center partnered with our medical library to create an evidence synthesis service aimed at infusing best research practices into strategy development and implementation. The hospital’s executive leadership team identified clinical and policy questions, and members of the hospital’s population health department worked closely with a medical librarian to complete literature searches, appraise evidence and summarize findings for leaders. These findings were used to inform strategy and implementation decisions. Examples of topics searched included the following: the most effective way to screen for SDoH needs, the best clinical data to use for predictive risk assessments, approaches to outreaching high risk patients, and the effectiveness of integrating behavioral health resources into clinics for patients with complex medical conditions.
This program led to the successful implementation of population health strategies for our healthcare system, and has benefited our community. The evidence synthesis service helped secure grant funding for two behavioral health resources for our adult and pediatric sickle cell disease clinics. This program also informed our enterprise-wide roll-out of SDoH screening and referral management. These are a few demonstrable ways the program has resulted in improvements in care delivery. Our population health strategy tactics each have metrics of success, which are monitored on our health system’s scorecard. Achievement of these measures will also serve as a way to monitor our program’s effectiveness going forward.