Population Health Learning Activities


Population health is defined as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group”1.  There are many health determinants — such as medical care systems, individual behaviors, genetics, and the social and physical environments — and each has a biological impact on individual and population health outcomes2.

Diversity and Health Literacy

Interprofessional (IP) Student Learning Activity related to Knowing and Managing Your Patients (KM) Competencies A and B; and Performance Measurement and Quality Improvement (QI) Competency A

Learning Activity Overview

  • An IP student team develops a report assessing language composition/diversity and health literacy of the practice’s patient population, which will be reviewed and revised with the practice team. The report should: 
    • Assess the practice’s materials in languages other than English (if appropriate) and explore possible strategies to address language challenges
    • Include a health literacy-based assessment of patient education materials
    • Include a brief literature review and population-specific practice performance data of disparities faced by at least one underserved population of the practice
    • Make recommendations to help reduce the identified disparities.
  • Advanced: During a patient encounter, members of the student team will use the teach-back (and/or show-me) method to ensure patient understanding of desired self-care behaviors.

Learning Objectives

  • Recognize the impact of language needs and diversity characteristics on health and health care.
  • Develop and demonstrate at least two health literacy skills such as are found in AHRQ’s Health Literacy Universal Precautions toolkit.
  • Assess for evidence of health disparities affecting a vulnerable group within the population served by the practice.
  • Assess patient education materials to identify and reduce barriers to patients’ abilities to access, understand and absorb health information.
  • Communicate information with patients, families, community members, and health team members in a form that is understandable, avoiding discipline-specific terminology when possible (CC2).
  • Embrace the cultural diversity and individual differences that characterize patients, populations, and the health team (VE3).

Population Health Profile

Interprofessional (IP) Student Learning Activity related to Knowing and Managing Your Patients (KM) Competencies A and B

Learning Activity Overview

The IP student team develops a health profile of the practice’s population. Using select Knowing and Managing Your Patients criteria, the team:

  • Compiles and analyzes the demographic and/or clinical data
  • Formats the data into a population health profile
  • Includes comparisons with existing community health profiles
  • Identifies challenges faced by the population of interest
  • Presents findings to appropriate practice members who, together with the students, will review and determine appropriate next steps

Learning Objectives

  • Using health informatics, develop a population health profile that can be effectively used to manage the health of the practice’s patient population.
  • Describe a community health assessment process and some of the most commonly used metrics and data sources.
  • Compare and contrast the patient population of the practice with that of the community, county, region, and/or state.
  • Place interests of patients and populations at center of interprofessional health care delivery and population healthy programs and policies, with the goal of promoting health and health equity across the lifespan (VE1)
  • Embrace the cultural diversity and individual differences that characterize patients, populations, and the health team (VE3).

Population Health Management Review

Interprofessional (IP) Student Learning Activity related to Patient-Centered Access and Continuity (AC) Competency A; Care Management and Support (CM) Competency A; and Knowing and Managing Your Patients (KM) Competency C

Population health management is “a set of interventions designed to maintain and improve a patient’s health across the full continuum of care – from low-risk, healthy individuals to high-risk individuals with one or more chronic condition(s)” (Felt-Lisk & Higgins, 2011)

Learning Activity Overview
An IP student team assesses the current strategies used by the practice to systematically identify and manage the health of its patient population.  The team:

  • Identifies areas of effectiveness and potential gaps
  • Determines if current practice adequately identifies and addresses the population’s needs
  • Conducts a literature review to identify evidence-based strategies and/or best practice to address the population’s identified health or healthcare need(s)
  • Drafts and presents a report that includes findings of their review and recommendations for improvement

Learning Objectives

  • Express one’s knowledge and opinions to team members involved in patient care and population health improvement with confidence, clarity, and respect, working to ensure common understanding of information, treatment, care decisions, and population health programs and policies (CC3).
  • Engage diverse professionals who complement one’s own professional expertise, as well as associated resources, to develop strategies to meet specific health and healthcare needs of patients and populations (RR3).
  • Use process improvement to increase effectiveness of interprofessional teamwork and team-based services, programs, and policies (TT9).
  • Place interests of patients and populations at center of interprofessional health care deliver and population health programs and policies, with the goal of promoting health and health equity across the lifespan (VE1).

Patient Engagement and Shared Decision-Making

Interprofessional (IP) Student Learning Activity related to Care Coordination and Care Transitions (CC) Competency A and Knowing and Managing Your Patients (KM) Competency F

Shared decision making (SDM) is “A process of communication in which clinicians and patients work together to make optimal healthcare decisions that align with what matters most to patients.  SDM requires three components: 1) clear, accurate, and unbiased medical evidence about reasonable alternatives — including no intervention — and the risks and benefits of each; 2) clinician expertise in communicating and tailoring that evidence for individual patients; and 3) patients values, goals, informed preferences, and concerns, which may include treatment burdens ” (National Quality Forum, 2017) 

Learning Activity Overview

  • An IP student team identifies a common health issue in the practice, then:
    • Reviews the practice’s patient decision support and self-management tools
    • Interviews appropriate stakeholders regarding the identified issue and adequacy of available resources
    • Assesses adequacy of existing resources
    • Determines whether and which additional evidence-based resources would address the identified health issue
    • Presents their findings and recommendations to appropriate practice team members
  • A practice team member or UNE educator will review with the IP student team:
    • Available patient self-management and SDM tools that address the practice’s most prevalent condition(s)
    • The practice’s process for tracking, monitoring, and reporting clinician and healthcare team engagement in SDM
  • Advanced: During a patient encounter, members of the student team will use a decision aid with a patient to clarify patient values and preferences to facilitate decision-making.

Learning Objectives

  • Develop a review and assessment of, and recommendations for, decision-support tools, self-care and decision-making aids for a particular health issue to assist the practice in meeting its patients’ needs.
  • Demonstrate shared decision making skills.
  • Use the full scope of knowledge, skills, and abilities of professionals from health and other fields to provide care that is safe, timely, efficient, effective, and equitable (RR5).
  • Integrate the knowledge and experience of health and other professions to inform health and care decisions, while respecting patient and community values and priorities/preferences for care (TT4).
  • Act with honesty and integrity in relationships with patients, families, communities, and other team members (VE9).

Quality Improvement (QI)

Interprofessional (IP) Student Learning Activity related to Performance Measurement and Quality Improvement (QI) Competencies A and B

Quality in health care is “a direct correlation between the level of improved health services and the desired health outcomes of individuals and populations.” (The National Academies Health and Medicine Division, formerly the Institutes of Medicine)

Quality improvement “consists of systematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.” (HRSA, 2011)

Learning Activity Overview
An IP student team will compile data to meet the requirements for at least ONE of the following:

  • Clinical Quality Measures (QI01)
  • Patient Experience Feedback (QI04)
  • Resource Stewardship Measures (QI02)
  • Health Disparities Assessment (QI05, QI07)

The student team will:

  • Identify and engage appropriate practice team members and patients/families/caregivers (if possible)
  • Analyze the chosen metric(s) and compare performance against practice standards, peer data and/or established benchmarks
  • Identify current strategies underway by the practice to address the measure(s)
  • Develop evidence-based recommendations for further improvements
  • Present findings to appropriate members of the practice team
  • If time allows, the student team may participate in or implement a rapid-cycle improvement process, such as Plan-Do-Study-Act (PDSA), of the selected performance measure(s)

Learning Objectives

  • Demonstrate the basic principles and skills of healthcare quality improvement.
  • Articulate common measures, challenges, impacts on health and healthcare, and strategies related to the chosen QI measure.
  • Engage in continuous professional and interprofessional development to enhance team performance and collaboration (RR8).
  • Reflect on individual and team performance for individual, as well as team, performance improvement (TT8).
  • Use process improvement to increase effectiveness of interprofessional teamwork and team-based services, programs, and policies (TT9).
  • Demonstrate high standards of ethical conduct and quality of care in contributions to team-based care (VE7).

Review of Any Concept

Interprofessional (IP) Student Learning Activity related to any Concept, Competency and Criterion

Learning Activity

  • An IP student team will:
  • Select any competency and criterion within a concept;
  • Review how the practice implements it;
  • Develop recommendations for more comprehensive, effective or efficient implementation
  • Prepare a report of its findings.

The process can involve interviewing practice team members to obtain input; conducting a literature review; researching strategies suggested by NCQA, IHI, AHRQ, and other organizations; and discussing issues with patients.

IP Student Learning Assessment
The student team will present its findings, including recommendations, to appropriate members of the practice team, who will provide the students with written feedback on the strengths of its work and areas of needed improvement.

Following this presentation, the student team, preceptor(s) and/or facilitator will debrief the experience of working together as a team on this Learning Activity.

Learning Objectives

  • Develop a review of, assessment of, and plan for the implementation of an NCQA concept, competency or criterion for achieving/maintaining PCMH recognition.
  • Articulate how PCMH standards and strategies fit into overall federal health quality initiatives.
  • Use unique and complementary abilities of all members of the team to optimize health and patient care (RR9).
  • Listen actively, and encourage ideas and opinions of other team members (CC4).

1: Kindig DA & Stoddart G. (2003).  What is population health? American Journal of Public Health, 93, 366-369.
2: Kindig DA (Ed.).  (n.d.).  What is population health?  [web log post].  Retrieved from http://www.improvingpopulationhealth.org/blog/what-is-population-health.html.