Population health management within the primary care context – scoping review

TL;DR

This scoping review examines how population health management is understood and applied within primary care settings.

Contribution

The study clarifies how primary care practices engage with population health management concepts and social determinants of health.

Findings

Definitions of PHM in primary care often emphasize social determinants of health and proactive care.

General practices are increasingly involved in risk stratification and impact assessment using real-world data.

Team-based and technology-supported care is central to PHM implementation in primary care.

Abstract

Population health management (PHM) is increasingly promoted as a strategy to improve health outcomes, enhance healthcare quality, reduce costs, and, more recently, support clinician well-being and advance health equity – the Quintuple Aim. However, how PHM is conceptualised within the primary care context remains unclear. This scoping review explores how PHM is conceptualised within this context.

Five databases (PubMed, Embase, CINAHL, Web of Science and Scopus) were searched to find publications that conceptually addressed PHM and its interaction with the primary care context. Data extraction focused on definitions and related terms, the bidirectional influence between PHM and general practice, and interpretations of the components ‘population’ and ‘management’.

27 publications were included. Definitions of PHM varied, with few explicitly addressing the primary care practice level. They highlighted the need to proactively address social determinants of health beyond clinical outcomes. Both top-down and bottom-up dynamics make general practices accountable for and increasingly involved in the identification of populations, risk stratification and impact assessment, with both clinical judgement and real-world primary care data. Management involves team-based and technology-supported care.

Considering PHM within primary care highlighted the importance of general practice’s accountability, its consideration of social determinants of health beyond clinical outcomes and its community alignment to enhance equity. What the potential added value of general practitioner’s clinical intuition and real-world primary care data in assessing impact warrants additional exploration.

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