City of Philadelphia
Population Health Framework
The City of Philadelphia’s Department of Behavioral Health and Intellectual disAbility Services is committed to supporting the health and well-being of all Philadelphians. In recognition of the complex and evolving challenges facing our communities, DBHIDS applies a community-driven population health strategy that leverages community engagement and advanced analytics to achieve greater precision and equity in health and well-being outcomes.
What is community-driven precision population health?
Community-driven precision population health refers to the integrated application of community partnerships, participatory strategies, cross-department data sharing, and advanced data analytics to identify and address health disparities, support population health and well-being, and prevent morbidity and mortality.
Why is DBHIDS adopting a community-driven precision population health approach?
DBHIDS is adopting this approach to further advance Philadelphia’s ongoing transformation of care efforts.
This strategy integrates individuals with behavioral health needs into their communities and strengthens community-based responses to behavioral health challenges. By combining proven, community-centered strategies with advanced analytics, DBHIDS ensures that all Philadelphians are included in efforts to promote well-being, reduce disparities, and foster self-determination and resilience across communities.
The innovation of the DBHIDS approach lies in the integration of lessons learned from community-centered strategies with the most advanced analytical techniques available. By thoughtfully combining the insights gained through direct community engagement with advanced data analytics, DBHIDS enhances the precision and effectiveness of population health interventions. This integration ensures that population health strategies are not only informed by robust data but are also deeply responsive to the unique needs and experiences of all communities, particularly those that have historically been underrepresented in public health datasets. As a result, DBHIDS advances a model of population health that is both equitable and evidence-based, reflecting a commitment to continuous improvement and inclusive care for all Philadelphians.
Through this approach, DBHIDS recognizes and acts upon the significant impact of historical, social, environmental, and economic factors on behavioral health and disAbility, tailoring prevention efforts to the unique needs of individuals and communities. The result is a more equitable, comprehensive, and effective system that promotes health and well-being for all Philadelphians.
The essence of our community driven precision population health approach is as follows:
- Attend to the whole population, not just to those seeking services. Our approach emphasizes the strengths and needs of all Philadelphians, not just those seeking services, and supports inclusive and tailored wellness and prevention strategies for the entire population.
- Promote health, wellness, and self-determination across the life-spam. Our approach ensures that prevention and support interventions are developmentally appropriate, culturally tailored, inclusive, and responsive to community needs and strengths, thereby promoting health, wellness, and self-determination for all Philadelphians.
- Provide early intervention and prevention. This approach proactively identifies risks and emerging health challenges through advanced analytics and community engagement, enabling early intervention and targeted prevention strategies that reduce the onset and escalation of poor health conditions for all Philadelphians.
- Address the social determinants of health. This approach seeks to identify and mitigate barriers such as housing, employment, education, transportation, and food security, fostering equitable health outcomes for all Philadelphians. The identification and mitigation of SDOH is essential for supporting individual and community well-being, and integral to the effective delivery of care. By prioritizing this model, DBHIDS ensures that interventions are comprehensive, responsive, and capable of addressing the root causes of health disparities, ultimately enhancing both the quality and equity of prevention and clinical services.
- Empower individuals and communities to keep themselves healthy. This approach equips Philadelphians with tailored resources, knowledge, and support to proactively manage their behavioral health and well-being, and foster collective and individual responsibility for healthier, more resilient communities.
How do we advance this work?
DBHIDS’ community-driven precision population health approach is a system-wide population health model that expands the scope and scale of prior efforts. This approach integrates systems across the public and private sectors. This means bringing together stakeholders from across the healthcare continuum with organizations beyond traditional health care systems such as schools, park services, churches, community gardens, and other community-based entities, to form a network dedicated to population behavioral health improvement.
By fostering robust public-private collaborations and advancing community partnerships, this integrated strategy ensures that initiatives are coordinated, resources are optimized, and interventions are responsive to the diverse and evolving needs of the population. A systems integration approach leverages the strengths of each sector, promotes shared accountability, and amplifies the impact of health and wellness efforts across all areas of society.
Integrating a community-driven precision population health approach into DBHIDS service systems requires that we assess what has been accomplished and how this work can be further supported. We start by asking the questions below.
What communities and needs are absent from the record?
We engage community partners to help us identify gaps in the data and the evidence. We focus on their strengths and support their agency. Examples of this work include the Resiliency in Communities After Stress and Trauma (ReCAST) and the Engaging Males of Color (EMOC) collaborations. These DBHIDS-community collaborations enhance public data and scientific evidence, inform more effective interventions to meet community needs, and strengthen the public response for Philadelphians affected by trauma and social unrest.
Community-driven Population Health in Practice
Philadelphia is part of a population health movement that leverages community engagement and advanced analytics to achieve greater precision and equity in health and well-being through public practices that address both individual and community needs. This approach ensures that groups historically absent from the record participate in public health decisions, that services are responsive to the cultural and social context of each community, and that support reaches Philadelphians in the places where they live, learn, and work.
What strategies can strengthen DBHIDS community outreach efforts?
Building on our extensive network of community partners, we continually innovate our outreach to engage groups we have not previously worked with. For example, we leverage data to better understand the linguistic and cultural needs of Philadelphians, and translate materials to effectively reach diverse residents. One example, Network of Neighbors, is a DBHIDS crisis response program that trains community members to lead responses to stress, trauma, loss, and violence within their own communities. Another initiative integrates Google Analytics with public data to connect consumers with healthymindsphilly.org and the resources they need.
How can we bring population health to the places where people meet in person or online?
We bring population health to community spaces by partnering with local organizations, using community navigators for tailored outreach, leveraging data to identify needs, and delivering services where people gather, making health resources accessible, relevant, and responsive to every group’s context. For example, DBHIDS continues to expand services beyond behavioral and clinical settings with programs such as the mobile wound care team, which responds to medical needs of those struggling with opioid use disorders on Philadelphia’s streets. We also meet people online by sharing health information through digital platforms, hosting virtual support groups, and providing resources via social media and community websites. For example, DBHIDS hosts online peer-support groups for survivors of suicide loss open for the community and free of cost.
How can we use community-driven precision population health to advance equality?
Equity is a guiding principle of our collaborative, advanced, and dynamic analytical approach. We use community partnerships and advanced analytics to improve the public record, identify emerging trends, anticipate risks, and allocate resources with unprecedented accuracy and effectiveness. This leads to the equitable and fiscally responsible distribution of services across communities.
Takeaway
The City of Philadelphia Department of Behavioral Health and Intellectual disAbility Services plays an important role in supporting the health and well-being of all Philadelphians. Our community-driven precision population health approach builds on decades of DBHIDS’s success as a community-engaged organization and steward of data and evidence-based public health, integrating these strengths with the most advanced analytic strategies to ensure equitable, responsive, and efficient population health for everyone in our city.