Assessing general practitioners’ perceived self-competence in applying Population Health Management (PHM) as an indicator of PHM implementation.

Background: Population Health Management (PHM) is increasingly implemented in routine clinical practice as healthcare systems aim to achieve the quintuple aim outcomes. As a proactive and data-driven approach, PHM utilizes data on health and social determinants of health to identify population needs and risk profiles, facilitating earlier and more targeted interventions. This study introduces a self-efficacy questionnaire designed to evaluate general practitioners’ (GPs) perceived self-competence in performing PHM-related tasks, based on their knowledge and skills, as a proxy for the evaluation of PHM implementation.

 

Approach: A qualitative approach was employed to develop questionnaire items assessing GPs’ perceived self-competence in performing PHM-related tasks, serving as a proxy for PHM implementation in general practice. A focus group comprising nine experts – including PHM implementation and evaluation specialists as well as GPs – collaboratively co-designed the questionnaire. Key PHM competencies were identified and translated into specific actions, supported by relevant national and local GP-specific examples of PHM. Thematic analysis was used to structure the items, with actions framed as: “To what extent do you consider yourself capable of…”. The questionnaire has been refined based on feedback from GPs actively integrating PHM into their routine clinical practice.

 

Results: Six PHM themes, encompassing 21 competencies and 31 actions, were defined for assessing perceived self-competence in PHM implementation in primary care: 1) using electronic medical records for documentation, care planning, … (Nactions = 4); 2) population identification using health and contextual data (N=2); 3) evaluating practice performance with evidence-based indicators (N=9); 4) aligning practice policy with patient needs (N=2); 5) proactive, personalized communication (N=5); and 6) multidisciplinary collaboration, including digital documentation and referrals (N=9). Each competency was linked to actions and GP-specific examples of PHM, reflecting the diverse skill set needed for effective PHM.

 

Implications: By specifying PHM-related competencies and corresponding actions, the results of this self-efficacy questionnaire – designed to assess GPs perceived self-competence in performing PHM-related tasks – serve as a proxy for evaluating PHM implementation in primary care. The questionnaire’s comprehensive scope reflects both the complexity and evolving nature of PHM. Completing the questionnaire enables assessment of the current state of PHM implementation and the identification of specific challenges encountered in practice. These insights can inform policymakers, implementation scientists, educators, and healthcare professionals about areas where primary care providers experience difficulties, thereby supporting the development of targeted educational and implementation strategies to address identified knowledge and skill gaps.

Although the current examples of PHM initiatives are tailored to the Belgian GP context, the generically defined competencies and actions support broader applicability. The tool can be adapted to evaluate PHM implementation by other primary care professionals by linking discipline-specific examples to the existing competencies and actions. For international application, it can be customized by contextualizing these examples to align with local healthcare systems. In both cases, consultation with an expert panel is recommended to ensure content validity.