White Papers on Population Health Management and Population Segmentation

The enactment of the Connecting Care Act in Ontario in 2019 launched a number of health system reforms, including the creation of Ontario Health Teams (OHTs). Under the Act, OHTs have a mandate to organize and deliver care using a Population Health Management (PHM) approach. These reports aim to provide practical information to leaders, managers, and practitioners involved in the creation and implementation of OHTs derived from international examples of PHM initiatives. The reports outline the future vision for population health management that could be achieved by OHTs. They outline the essential steps to implement population health management with particular attention to the tools and practices associated with population segmentation as a data-informed strategy for population health improvement.


Report 1: Approaches to Population Health Management: Informing Ontario’s Health System Transformation

Population health management (PHM) is the concept of gathering data and insights about population health and well-being across multiple care and service settings, with a view to identifying the main health and social needs of the community and adapting services accordingly. This is accomplished by integrating services across health, prevention, social, and welfare services. This report aims to provide practical information to leaders, managers, and practitioners involved in the creation and implementation of OHTs using an array of examples of international PHM initiatives. We report on 3 programs: Kaiser Permanente Washington, USA; Jonkoping, Sweden; and Gesundes Kinzigtal, Germany; and 2 national programs in Singapore and the Netherlands. Conditions for success and learnings from other systems are identified as they relate to OHTs.

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Report 2: A Review of Population Segmentation Tools for Population Health Management: Applicability for Ontario Health Teams

In their first year, Ontario Health Team candidates were asked to select target population segments with the greatest potential for significant impact. As OHTs mature, they will be responsible for their whole attributed population while emphasizing high-risk and specific sub-populations. The emphasis on population segments or sub-groups requires that OHTs segment their attributed populations into population sub-groups with shared needs. This report was prepared for OHTs interested in applying population segmentation tools for population health management. The report focuses on the tools and their characteristics and describes how they were actioned in practice. A rapid scoping review approach was taken to enable a wide array of segmentation approaches to be included. We review and summarize essential characteristics from 25 peer reviewed publications on population segmentation designed for use in health care systems. This rapid review summarizes population segmentation tools aimed at supporting population health management to inform the choice of segmentation tools that may be considered by Ontario Health Teams.

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Report 3: Real World Applications of Population Segmentation in Population Health Management

Population segmentation is an important tool for implementing population health management within a health system since care needs will vary across individuals in the served population.  Through segmentation, the unique care needs of heterogeneous groups are identified, enabling targeted interventions, policies and financing for each subgroup. This enables the system to match the appropriate services to the appropriate individuals to optimize their health outcomes as well as to improve healthcare service planning at population level. The purpose of this report is to describe how population segmentation is practically applied within health care systems that have implemented population health management. Through an analysis of three international health systems this report highlights the key success factors and challenges in implementing segmentation. We report on the use of segmentation for population health in 3 integrated care systems: Denver Health, USA; Gesundes Kinzigtal, Germany; and North West London; England. We find that population segmentation is a tool within a number of equally important tools and strategies required to help achieve population health management.

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