DHA 731 Week 1 Population Health for Health Care Leaders Example

One in Five Adults With Diabetes: Why a Rural Health System Leader Must Think in Populations, Not Patients

[Student Name]

University of Phoenix

DHA/731: Population Health and Epidemiology

Week 1 Assignment

[Instructor Name]

[Date]

The health network, its leaders and plans are composites written for a model paper. County figures are real CDC PLACES 2025 release estimates for Bertie, Halifax, Hertford and Northampton counties in North Carolina and BRFSS 2023 state estimates; research findings come from the sources cited.

At a board retreat, a trustee asked the regional vice president why the rural hospitals should spend money on food programs, transportation and community health workers when their job was to treat patients. The question is common, and it deserves a careful answer. This paper answers it by introducing population health and applying it to the region the hospitals serve, represented here by four northeastern North Carolina counties, Bertie, Halifax, Hertford and Northampton, home to about 100,000 people.

Defining Population Health

Kindig and Stoddart argued that the term should describe the health of a defined group of people, counting not just the group's average but how unevenly health is spread among its members; the field, in their view, joins those outcomes to the forces that produce them and to the policies that connect the two (Kindig & Stoddart, 2003). The definition matters for two reasons: it focuses on outcomes for everyone in a population, not only those who seek care, and it asks how evenly those outcomes are shared.

Population Health, Clinical Care and Public Health

Clinical care treats individual patients who come for help. Public health agencies protect communities through surveillance, prevention and regulation. Population health overlaps both but is defined by its focus on outcomes for a whole population and on the full set of determinants, which gives health systems a role alongside public health departments.

A Model of Determinants

The County Health Rankings model organizes the determinants of health. Remington and colleagues explain that the Rankings score each county on how long and how well people live and on four groups of factors behind those outcomes: behaviors, medical care, the economic and social conditions of residents and the built and natural surroundings. Counties are ranked only against others in the same state, and gaps inside a single state are large, often more than double between the best and worst counties for early deaths, teen births and children in poverty (Remington et al., 2015). In the model's weighting, social and economic factors carry 40% of the weight, health behaviors 30%, clinical care 20% and the physical environment 10%.

What the Weights Mean for a Hospital

If clinical care accounts for about a fifth of the modifiable influences on health, a hospital that confines itself to clinical care addresses only part of what shapes its community's health. A hospital that works only inside its walls is working on a fifth of the problem.

The Region's Health: Chronic Disease

CDC PLACES estimates for 2023 show a heavy burden of chronic disease. Crude prevalence of diagnosed diabetes among adults ranged from 18.9% in Hertford County to 20.3% in Northampton County, and high blood pressure from 48.1% in Hertford to 52.0% in Northampton (Centers for Disease Control and Prevention [CDC], 2025a). Obesity was about 43% in all four counties, a leading risk factor for both diabetes and high blood pressure in every county.

Comparing With the State

Statewide, the Behavioral Risk Factor Surveillance System, which interviews adults by phone in all fifty states each year, estimated diagnosed diabetes among North Carolina adults at 12.4% and current smoking at 13.2% in 2023 (CDC, 2025b). In the four counties, crude smoking prevalence ranged from 17.2% to 19.8% (CDC, 2025a). On both measures, the region's adults fare worse than the state as a whole.

Crude and Age-Adjusted Rates

The comparison needs care. The four counties are older than the state, and older adults have more diabetes. Age-adjusted diabetes prevalence, which removes differences in age structure, ranged from 14.2% to 15.2% (CDC, 2025a), lower than the crude figures but still above the state's crude rate. Older residents account for some of the difference; the rest remains after adjustment.

Social and Economic Factors

PLACES also estimates social needs. Food insecurity in the past year was reported by 23.9% of adults in Northampton County to 29.1% in Halifax County, and lack of reliable transportation kept 11.8% to 14.4% of adults from medical care, meetings, work or daily needs (CDC, 2025a). About one adult in eight lacked health insurance before the state's Medicaid expansion took full effect.

Distribution Within the Region

Averages hide differences. Within each county, diabetes and high blood pressure are more common among Black residents and among residents with lower incomes, and tract-level estimates show pockets with far higher burdens. Kindig and Stoddart's definition directs leaders to these distributions, not only to county averages.

Using the Rankings Locally

The Rankings have placed several of these counties among the least healthy in North Carolina's hundred counties, a fact local officials know well. Because the Rankings compare counties within a state, they invite neighboring counties to learn from one another, and they give hospital boards a public benchmark. The authors caution that no model captures everything, and they urge users to add local data, which is why the region pairs the Rankings with PLACES estimates and its own clinical records.

Why Leaders Should Think in Populations

The case for a population perspective is practical as well as moral. Under value-based contracts, the hospitals are responsible for the health of attributed populations, not only for admitted patients. Chronic disease drives avoidable admissions, which strain small hospitals and cost payers. And social needs such as food insecurity and transportation directly affect whether patients can manage their conditions.

Priority One: Diabetes and Blood Pressure Control

The region will focus first on the two most common chronic conditions, using registries, care teams and community health workers to reach adults who are not in regular care. With roughly one adult in five living with diabetes and half with high blood pressure, even modest improvements in control would prevent strokes, heart attacks, kidney failure and amputations.

Priority Two: Food Insecurity

The hospitals will screen patients for food insecurity and partner with food banks and the state's social needs services to connect them with help. For patients with diabetes, food insecurity makes it hard to follow a diet and can cause dangerous swings in blood sugar, so the two priorities reinforce each other.

Priority Three: Transportation

The region will fund rides to appointments and expand telehealth and mobile services in the most isolated areas, starting with the census tracts where PLACES estimates show the highest share of adults without reliable transportation.

Measures and Data Sources

Progress will be tracked with PLACES estimates each year, the region's own clinical data on blood sugar and blood pressure control, screening results for social needs and County Health Rankings measures such as premature death.

Conclusion

Population health asks leaders to look at the health of everyone in their region and how that health is distributed. The County Health Rankings model shows that clinical care is only part of what shapes health. Real data show the region's adults face high rates of diabetes, high blood pressure, smoking, food insecurity and transportation barriers. Those facts answer the trustee: the hospitals' mission reaches beyond their walls.

References

Centers for Disease Control and Prevention. (2025a). PLACES: Local data for better health, county data, 2025 release [Data set]. data.cdc.gov. https://data.cdc.gov/d/swc5-untb

Centers for Disease Control and Prevention. (2025b). Behavioral Risk Factor Surveillance System (BRFSS) prevalence data (2011 to present) [Data set]. data.cdc.gov. https://data.cdc.gov/d/dttw-5yxu

Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93(3), 380-383. https://doi.org/10.2105/AJPH.93.3.380

Remington, P. L., Catlin, B. B., & Gennuso, K. P. (2015). The County Health Rankings: Rationale and methods. Population Health Metrics, 13, Article 11. https://doi.org/10.1186/s12963-015-0044-2