Reenvisioning Population Health Using a Surgical Lens

Abstract

Healthcare providers—both clinical and public health agencies—are increasingly encouraged to adopt community-based models that function at the intersection of provider and partner organizations. These models aim to develop community engagement strategies that support population health within the broader patient ecosystem. However, many existing strategies remain episodic in nature, addressing discrete phases such as prevention, hospital-based care, or post-discharge transitions. While they may adapt to changes in patient health status or access barriers, they often fall short in facilitating seamless transitions across the entire care journey—particularly for individuals managing chronic conditions. This raises a critical question: How are care transitions coordinated, and who is responsible for managing them?
This paper introduces a meta-community model network (meta-CMN) to facilitate patient transitions across various care models. The meta-CMN comprises network members representing the diverse community models that patients interact with—both upstream and downstream—on their path to managing chronic conditions and achieving health goals. We explore how these members align their objectives and coordinate resources through a multi-layered architecture, drawing on inter-organizational dynamic capability frameworks as well as communication and network theories.
To illustrate the utility of the meta-CMN, we apply it to the context of perioperative care for patients with nicotine addiction. We explore several coordination models for managing the meta-CMN, including leadership by a single network member, shared governance among multiple members, and the use of technological intermediaries such as blockchain. The paper concludes with recommendations and identifies opportunities for future research.