How one leading healthcare organization is addressing chronic health conditions as they relate to population health at large.
Many chronic diseases are caused by factors such as smoking, improper nutrition, physical inactivity and excessive alcohol use. Despite these causes being preventable, more than 75% of midlife (ages 35–64) adults in the U.S. have at least one chronic condition.
According to the Centers for Disease Control and Prevention (CDC), some groups are more affected than others by chronic disease because of factors that limit their ability to make healthy choices.
“Many of the factors impacting our health are driven by where we live and how we act,” said Christopher Stanley, MD, MBA, President of Populance. “If someone can’t pay their utility bills or put food on the table, it’s quite likely they won’t be able to focus on taking care of themselves, especially when it comes to health and doctor’s orders. We as the healthcare industry need to do what we can to help these individuals face these challenges and manage their stress.”
Populance, an organization advancing population health, was created to tackle the challenges of rising chronic conditions, inequities in care and fragmented care models. As a wholly owned subsidiary of Henry Ford Health, Populance was designed to transform the healthcare experience with focus and purpose by delivering smarter care for patients, providers and communities.
By partnering with physicians, hospitals and health plans to deliver value-based care solutions that improve outcomes and elevate the patient experience, Populance is able to lower the overall cost of care for at-need patients.
Enabled by the support of its own leadership and board, Populance can respond to ever-changing industry conditions and support its initial primary customers – Henry Ford Health subsidiaries Health Alliance Plan (payer) and the Mosaic Clinically Integrated Network (provider) – with agility and speed while developing economies of scale.
Filling in the gaps
In medicine, chronic disease is often approached as a clinical issue, but Dr. Stanley said that the increasing prevalence of disease also has a significant impact on population health at large.
“That’s why it’s so important that we care for everyone – to fill in the care gaps and make sure our physicians, facilities and even social workers are all working together to treat the whole person and ensure that each individual gets the care they need,” said Dr. Stanley.
As chronic disease reaches epidemic levels in the U.S., care delivery has had to evolve to address not just disease prevention, but also early detection and long-term management of chronic disease.
“We prioritize services we know will help people get and stay healthy and manage their chronic conditions,” said Dr. Stanley. “At Populance, our nurses, social workers and population health coordinators are embedded in nearly 60 clinics to support physicians by coordinating care for high-risk individuals with chronic conditions.”
Healthcare with Populance includes screening patients for the social determinants of health (SDOH) – or the nonmedical factors that influence health outcomes – such as the conditions in which people are born, grow, work, live, worship and age.
“Any patient we identify with a barrier – like lack of transportation or access to healthy food or risk of depression – is connected with one of our population health coordinators who works with community agencies to address their needs,” said Dr. Stanley.
Populance also supports its physician partners through the integration of multidisciplinary clinical teams that manage socioeconomic barriers to health.
“Ideally, the health care industry would focus on primary prevention – keeping disease from ever occurring,” said Dr. Stanley. “As we progress on this journey, we invest our resources and teams on addressing preventable events during a patient’s care journey.”
The Populance ‘Transitions of Care’ program, which focuses on the safe handoff of patients across care settings, is an example of this journey, where teams provide individual case management to address critical gaps in care for patients recently discharged from the hospital, especially those who are at high risk of readmission.
“Throughout 2025, we expanded our transitions of care support by integrating a digital outreach platform (autodial/text provided by vendor CipherHealth) with the existing clinical oversight provided by our Populance transitional care team,” said Dr. Stanley.
The hybrid technology and staff approach is designed to reduce readmissions through multichannel engagement, providing standardized risk screening for all discharged patients and maximizing per-call efficiency by providing actionable data even before outreach.
“High-value care is a mindset and delivery model that prioritizes outcomes, affordability and equity,” said Dr. Stanley. “We prioritize services we know will help people get and stay healthy and manage their chronic conditions, and we increase affordability by guiding people to the right care in the right place at the right time.”
Key Takeaways
- For some groups of people, chronic disease is more prevalent because of external factors that limit their ability to make healthy choices.
- Populance, a subsidiary of Henry Ford Health, was created to address the challenges of the rising prevalence of chronic conditions and fragmented, unequal care.
- Patients identified with barriers to care such as lack of transportation, access to healthy food, risk of depression and more are connected with one Populance’s population health coordinators who work with community agencies to assist them in navigating their healthcare.
- High-value care goes beyond treating illness by proactively identifying risks, coordinating care and addressing barriers before they lead to worse health outcomes.