Leveraging Communities for Population Health : Insights from a Large Scale Integrated Care Program in France

Starting in 2018, the French Hospitals Federation (FHF) has launched a large-scale Integrated Care/Population Health Program called “Responsabilité populationnelle” (Shared accountability for a population). 

Built around five “Pioneer” regions and two “target populations” (people at risk or suffering from Type 2 diabetes and Heart failure) it aims at joining all healthcare stakeholders in a given territory to create together shared clinical programs ranging from primary prevention to management of complex patients. Local stakeholders rely on health needs stratification and clinical decision-trees developed by FHF as well as local knowledge and lived experience to develop detailed health pathways and specific actions aimed at preventing diseases.

Mobilizing local communities and assets is key for the success of these population health program. We illustrate our point with three examples from our Pioneer Territories, each representing a dimension of a community: health at work, voluntary sector and local business community, all of which play a key role in population health.

 1) Working with occupational health services, our teams were able to organize screening and referral inside the workplace, making access easier for at risk professionals. 2) Working with local foodbanks: our teams are embedded in these structures, allowing early detection and inclusion of severely deprived population that lacked access to HC services, 3) Working with local businesses: our teams have set up operations inside supermarkets to offer preventive services, health advice, and inclusion in the program for those who need it.

Taken together, our Five Pioneer Territories have carried out more than 950 outreach actions in 22 months, screening 15 000 at risk individual. More than 5 000 patients are enrolled in personalized health pathways.

In these Territories, the share of ER admissions for diabetic patients has decreased by 33%, share of ambulatory stays has increased by 25% and share of long stays decreased by 50%. Average hospital costs for diabetic patients is 6% inferior to the national average, while our territories “find” 4% more diabetic patients than national average.

The ”Responsabilité populationnelle” model was designed to be scalable. 4 new Regions have joined the program in 2023 and have now completed their clinical programs. We will illustrate how these “new” Territories plan to leverage community resources in their environment.