4 Roles of Nurses in Population Health Management

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In 1915, C.E.A. Winslow, the first professor to found a university population health management department, established the definition of the discipline. He described it as “the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals.” This definition serves as a template for public health professionals.

Today, medical professionals have varied views about what population health management encompasses. Despite this, community health outcomes continue to improve as public health specialists deliver lifesaving messages to a growing number of at-risk consumers.

Regarding the actual delivery of those messages, community nurses provide health care organizations with a critical understanding of the cultural and socioeconomic determiners that affect service delivery. As such, nurses who practice in the following four roles assist care provider organizations in meeting relatively recent key legislative performance indicators that improve population health.

1. Care Coordinator

Nursing care coordinators work with individuals, groups, and communities to arrange resources that consumers need to ensure successful treatments. [1] These nurses ensure that various services complement each other in a way that promotes positive patient outcomes. This work serves to decrease service costs, facilitate provider collaboration, and increase patient safety. By thinking of their work on a community level, care coordinators make sure that patrons receive necessary services across population groups, treatment disciplines, and service sites.

For example, a consumer afflicted with Congestive Heart Failure (CHF) may require treatments from several specialists. This complex undertaking can expose patients to added risks. CHF patients face the additional risks of undergoing redundant diagnostics, and receiving conflicting or redundant medications, dietary plans, or physical therapy treatments. In these instances, a critical error can occur, resulting in the need for emergency services or worse.

Nursing care coordinators bridge the gaps between many disparate health services. They eliminate redundant treatments and make sure consumers understand how to comply with the care plans developed by multiple providers. This work promotes optimal treatment outcomes and reduces unnecessary readmissions.

2. Informatics Specialist

Nursing informatics specialists perform a critical role in helping improve treatment outcomes. [2] These professionals combine their expertise in communications and electronic information management to organize and disseminate information in a way that provides value to care providers and consumers. Many nurses who practice this discipline have frontline caregiving experience.

Informatics specialists typically perform work involving the technical or computer-related aspects of health care services. In an executive capacity, these nurses might make decisions that affect the way an entire organization manages patient information.

Nursing informatics professionals may specialize in one of several areas. Informatics research nurses commonly work at universities, private medical firms, and private health organizations. Consumer needs consultants create and maintain digital information that consumers can access using the Internet. Public health informatics specialists collect and analyze electronic health records (EHRs) and other data for use by consumers, medical professionals, and public health officials. Informatics specialists manipulate data that spans many health disciplines to improve community wellness and keep care providers up to date with timely population health statistics.

3. Community-Based Facilitator

Community-based facilitators support consumers and health care workers in transitioning to new practices. [3] The nurses serve as a link between medical theory and practice. In this role, nursing professionals play an important part in ensuring the medical community properly adopts procedural and policy changes based on the latest empirical health data.

While performing consumer-facing duties, the specialists help individuals, groups, and communities understand why and how they need to make changes in the habits that affect their health. By creating specific goals, community-based facilitators serve as intermediaries who guide health professionals in achieving pre-established objectives.

Depending on the focus area, community-based facilitators might perform duties that include small tasks for individuals, to wide-ranging overall community plans that promote holistic wellness. These nursing professionals typically work in universities and health care academic settings; teaching medical students and care providers how to implement new practices based on recent scientific discoveries.

The consensus among medical professionals is that community-based facilitation makes it easier for consumers and health care professionals to adopt new methods and behaviors. Some health experts support the idea that the practice encourages cooperation among consumers and professional peers. Either view focuses on improving the quality of health services.

4. Primary Care Partner

The United States currently suffers from a shortage of primary care providers, and may have difficulty serving the needs of a growing patient population. [4] As caseloads increase, health care organizations must transition toward new practice models and streamlined operations.

In response to these conditions, more nurses have assumed the role of primary care partner. However, the key to this transition lies in training sufficient numbers of nurses to pursue this career track.

Increasing the ranks of primary care providers and reorganizing service delivery will help health care organizations improve patient treatment experiences and outcomes while reducing medical expenses. The 3.7 million registered nurses (RNs) who currently practice in America represent a ready and able resource that can help alleviate the shortage of primary care providers. Advanced practice nurses who assume roles as primary care partners can relieve the growing pressure placed on many health organizations in the United States.

Despite these options, many health care organizations do not utilize RNs to their full potential as primary care providers. However, among the organizations that have employed RNs in this capacity, patient satisfaction and health outcomes have risen, and operating costs have decreased.

Population health rests with the ability to provide tangible services of proven value to patients. This requires fostering teamwork, cultivating collaborative relationships, and streamlining operations throughout the public health care milieu. Ultimately, successful community wellness may lie in the hands of skilled, advanced nursing professionals who can help health organizations meet, and exceed, these objectives.

Learn More

Family nurse practitioners play a major role in today’s health care field. The responsibilities of FNPs have evolved alongside that of physicians, which means additional opportunities, autonomy, and authority. At Regis College, our online Master of Science in Nursing Family Nurse Practitioner degree can help you develop the specialized skill set you need to practice at the advanced level.

Recommended Readings

Best Practices to Promote Cultural Awareness
How Nurse Practitioners Can Become Community Advocates
10 Tips for Nurses to Effectively Communicate with Elderly Patients


[1] FreemanWhite
[2] Wiley Online Library