Population Health as a Network of Services: Integration of Health, Education, and Social Services

  • William B. RouseEmail author
  • Kara M. Pepe
  • Michael M. E. Johns
Part of the Service Science: Research and Innovations in the Service Economy book series (SSRI)


This chapter focuses on how population health can be conceptualized and managed as a large multi-level network of services. Specifically, how can we deliver the health, education, and social services to keep a representative population healthy within the highly fragmented US delivery system? A central consideration is the coordination of care, ranging from prevention and wellness, to chronic disease management, to acute care and managing the transition of patients from hospital to home, as well as from home to follow up visits and social services. This chapter addresses the issues and possible model-based solutions to successfully managing this whole process. A case study of substance abuse is discussed.


Population health Service supply chains Care coordination 


  1. Al-Saa’da, R.J., et al. (2013). Supply chain management and its effect on healthcare service quality: Quantitative evidence from Jordanian private hospitals. Journal of Management and Strategy, 4 (2), 42-51.Google Scholar
  2. Bailey, D.J. (2017). Value-based care alone won’t reduce health spending and improve patient outcomes, Harvard Business Review, June 16Google Scholar
  3. Baltacioglu, T., Ada, H., Kaplan, M.D., Yurt, O., & Kaplan, Y.C. (2007). A new framework for service supply chains. Service Industries Journal, 27 (2), 105-124.CrossRefGoogle Scholar
  4. Ben-Ari, A. (2015). Analysis of an Outpatient Consultation Network in a Veterans Administration Health Care System Hospital. Palo Alto, CA: Stanford University.Google Scholar
  5. Bradley, E. & Taylor, L.A. (2013). The American Health Care Paradox: Why Spending More is Getting Us Less. New York: Public Affairs.Google Scholar
  6. Brandenburg, L., Gabow, P., Steele, G., Toussaint, J., & Tyson, B.J. (2015). Innovation and Best Practices in Health Care Scheduling. Washington, DC: Institute of Medicine.Google Scholar
  7. Brunette, M.F., Mueser, K.T., & Drake, R.E. (2004). A review of research on residential programs for people with severe mental illness and co-occurring substance abuse disorders. Drug and Alcohol Review, 23, 471-481.CrossRefGoogle Scholar
  8. Burwell, S. M. (2015). Setting value-based payment goals—HHS efforts to improve US health care. New England Journal of Medicine, 372 (10), 897-899.CrossRefGoogle Scholar
  9. Carr, C.J.A., Xu, J., Redko, C., Lane, D.T., Rapp, R.C., Goris, J., & Carlson, R.G. (2008). Individual and system influences on waiting time for substance abuse treatment. Journal of Substance Abuse Treatment, 34 (2), 192-201.CrossRefGoogle Scholar
  10. Casalino, L.P., Erb, N., Joshi, M.S., & Shortell, S.M. (2015). Accountable Care Organizations and Population Health Organizations. Journal of Health Politics, Policy, and Law, 40 (4), 819-835.CrossRefGoogle Scholar
  11. Choi, T-M., Wallace, S.W., & Wang, Y. (2016). Risk management and coordination in service supply chains: Information, logistics, and outsourcing. Journal of the Operational Research Society, 67, 159-164.CrossRefGoogle Scholar
  12. CMS (2015). Shared Savings and Losses and Assignment Methodology: Version 4, December. Baltimore, MD: Centers for Medicare and Medicaid Services.Google Scholar
  13. Cooper, R. (2016). Poverty and the Myths of Health Care Reform. Baltimore, MD: Johns Hopkins University Press.Google Scholar
  14. Coviello, D.M., Zanis, D.A., Wesnoski, S.A., Palman, N., Gur, A., Lynch, K.G., & McKay, J.R. (2013). Does mandating offenders to treatment improve completion rates? Journal of Substance Abuse Treatment, 44 (4), 417-425.CrossRefGoogle Scholar
  15. Curran, J.W. (2013). Social Determinants of Health in the United States: Roles and Limitations of the Academic Health Center. Atlanta, GA: Emory University, Rollins School of Public Health.Google Scholar
  16. Decker, K., & Lesser, V.R. (1995). Coordination Assistance for Mixed Human and Computational Agent Systems. Amherst, MA: University of Massachusetts.Google Scholar
  17. Decker, K., & Li, J. (2004). Coordinated hospital patient scheduling. Proceedings of the Tenth Americas Conference on Information Systems, 104-111.Google Scholar
  18. Desai, S., Hatfield, L.A., Hicks, A.L., Sinaiko, A.D., Chernew, M.E., Cowling, D., Gautam, S., Wu, S-J., & Mehrotra, A. (2017). Offering a price transparency tool did not reduce overall spending among California public employees and retirees. Health Affairs, 36 (8), 1401-1407.CrossRefGoogle Scholar
  19. Dickson, V. (2015). Medicaid plans struggle to provide mental health services. Modern Healthcare, July 4.Google Scholar
  20. Drake, R.E., Mercer-McFadden, C., Mueser, K.T., McHugo, G.J., & Bond, J.R. (1998). Review on integrated mental health and substance abuse treatment for patients with dual disorders. Schizophrenia Bulletin, 24 (4), 589-608.CrossRefGoogle Scholar
  21. DuPont, R.L. (2014). Creating a New Standard for Addiction Treatment Outcomes. Rockville, MD: Institute for Behavior and Health.Google Scholar
  22. Ellram, L.M., Tate, W.L., & Billington, C. (2004). Understanding and managing the services supply chain. Journal of Supply Chain Management, Fall, 17-32.Google Scholar
  23. EOP (2012). Fact Sheet. Washington, DC: Office of National Drug Control Policy, Executive Office of the President.Google Scholar
  24. Estee, S., & Norlund, D. (2003). Washington State Supplemental Security Income (SSI) Cost Offset Pilot Project: 2002 Project Report. Olympia, WA: Washington State Services Division.Google Scholar
  25. Ettner, S.L., Huang, D., Evans, E., Ash, D.R., Hardy, M., Jourabchi, M., & Hser, Y. (2006). Benefit–cost in the California treatment outcome project: Does substance abuse treatment “pay for itself”? Health Services Research, 41 (1), 192-213.CrossRefGoogle Scholar
  26. Fowler, J.H. (2008). Dynamic spread of happiness in a large social network: Longitudinal analysis over 20 years in the Framingham Heart Study. BMJ, 337, a2338.CrossRefGoogle Scholar
  27. Galea, S., Tracy, M., Hoggatt, K. J., DiMaggio, C., & Karpati, A. (2011). Estimated deaths attributable to social factors in the United States. American Journal of Public Health, 101 (8), 1456-1465.CrossRefGoogle Scholar
  28. Hall, R. (2013). Patient Flow: Reducing Delay in Healthcare Delivery. New York: Springer.CrossRefGoogle Scholar
  29. HHS (2016). National Projections of Supply and Demand for Selected Behavioral Health Practitioners: 2013-2025. Washington, DC: Department of Health and Human Services.Google Scholar
  30. IOM (2015). Integrating Research and Practice: Health System Leaders Working Toward High-Value Care. Washington, DC: National Academy Press.Google Scholar
  31. Johns, M.M.E., Lewin, J.S., & Jain, S.H. (2016). One path to value-based care for academic health centers. New England Journal of Medicine Catalyst, May 4.Google Scholar
  32. Johnson, S.R. (2016). Demand of for mental health services soars amid provider shortage. Modern Healthcare, December 31.Google Scholar
  33. Kahneman, D. (2011). Thinking, Fast and Slow. New York: Farrar, Straus and Giroux.Google Scholar
  34. Kaplan, G., Lopez, M.H., & McGinnis, J.M. (Eds.). (2015). Transforming Health Care Access and Scheduling: Getting to Now. Washington, DC: National Academies Press.Google Scholar
  35. Kindig, D., & Stoddart, G. (2003). What is population health? American Journal of Public Health, 93 (3), 380-383.CrossRefGoogle Scholar
  36. Lipari, R.N., Park-Lee, E., & Van Horn, S. (2016). America's need for and receipt of substance use treatment in 2015. The CBHSQ Report, September 29.Google Scholar
  37. Livingston, S. (2017). Insurers slowly removing barriers to addiction treatment. Modern Healthcare, April 14.Google Scholar
  38. Marlatt, G.A., Blume, A.W., & Parks, G.A. (2001). Integrated harm reduction therapy and traditional substance abuse treatment. Journal of Psychoactive Design, 33 (1), 13-21.CrossRefGoogle Scholar
  39. Marmot, M., Friel, S., Bell, R., Houweling, T. A., Taylor, S., & Commission on Social Determinants of Health. (2008). Closing the gap in a generation: health equity through action on the social determinants of health. The Lancet, 372 (9650), 1661-1669.CrossRefGoogle Scholar
  40. McLaughlin, C.G. (2004). Delays in treatment for mental disorders and health insurance coverage. Health Services Research, 39 (2), 221-224.CrossRefGoogle Scholar
  41. McVay, D., Schiraldi, V., & Ziedenberg, J. (2004). Treatment or Incarceration? National and State Findings on the Efficacy and Cost Savings of Drug Treatment Versus Imprisonment. Washington, DC: Justice Policy Institute.Google Scholar
  42. Meara, E., & Frank, R.G. (2005). Spending on substance abuse treatment: How much is enough? Addiction, 100 (9), 1240-1248.CrossRefGoogle Scholar
  43. NIH (2011). Treatment Statistics. North Bethesda, MD: National Institute on Drug Abuse.Google Scholar
  44. NIH (2012). How Effective Is Drug Addiction Treatment? Washington, DC: National Institute on Drug Abuse.Google Scholar
  45. NIH (2016). Trends and Statistics. Washington, DC: National Institute on Drug Abuse.Google Scholar
  46. NIH (2017). Overdose Death Rates. North Bethesda, MD: National Institute on Drug Abuse.Google Scholar
  47. NTA (2012). The Role of Residential Rehab in an Integrated Treatment System. London, UK: National Treatment Agency for Substance Misuse, National Health Service.Google Scholar
  48. Olsen, Y., & Sharfstein, J.M. (2014). Confronting the stigma of opioid use disorder – And its treatment. JAMA, 311 (14), 1393-1394.CrossRefGoogle Scholar
  49. ONC (2015). Connecting Health and Care for the Nation: A Shared Nationwide Interoperability Roadmap. Washington, DC: Office of the National Coordinator for Health Information Technology.Google Scholar
  50. Park, H., Clear, T., Rouse, W.B., Basole, R.C., Braunstein, M.L., Brigham, K.L., & Cunningham, L. (2012). Multi-level simulations of health delivery systems. A prospective tool for policy, strategy, planning and management. Journal of Service Science, 4 (3), 253-268.CrossRefGoogle Scholar
  51. Post (2017). Chicago will require high school students to have a plan after graduation. Good. The Washington Post, July 8.Google Scholar
  52. Porter, J., & Jick, H. (1980). Addiction rare in patients treated with narcotics. New England Journal of Medicine, 302, 123.Google Scholar
  53. Quinones, S. (2015). Dreamland: The True Tale of America’s Opiate Epidemic. New York: Bloomsbury Press.Google Scholar
  54. Radley, D. C., & Schoen, C. (2012). Geographic variation in access to care—the relationship with quality. New England Journal of Medicine, 367 (1), 3-6.CrossRefGoogle Scholar
  55. Redko, C., Rapp, R.C., & Carlson, R.G. (2006). Waiting time as a barrier to treatment entry: Perceptions of substance abusers. Journal of Drug Issues, 36 (4), 831-852.CrossRefGoogle Scholar
  56. Rouse, W.B. (2015). Modeling and Visualization of Complex Systems and Enterprises: Explorations of Physical, Human, Economic, and Social Phenomena. Hoboken, NJ: John Wiley.CrossRefGoogle Scholar
  57. Rouse, W.B. (2016). Universities as Complex Enterprises: How Academia Works, Why It Works These Ways, and Where the University Enterprise Is Headed. Hoboken, NJ: John Wiley & Sons.CrossRefGoogle Scholar
  58. Rouse, W.B., & Cortese, D.A. (Eds.). (2010). Engineering the System of Healthcare Delivery. Amsterdam: IOS Press.Google Scholar
  59. Rouse, W.B., Johns, M.M.E., & Pepe, K. (2017). Learning in the health care enterprise. Journal of Learning Health Systems, 1 (4).CrossRefGoogle Scholar
  60. Rouse, W.B., & Serban, N. (2014). Understanding and Managing the Complexity of Healthcare. Cambridge, MA: MIT Press.Google Scholar
  61. Ryu, J., & Lee, T.H. (2017). The waiting game – Why providers may fail to reduce wait times. New England Journal of Medicine, 376 (24), 2309-2311.CrossRefGoogle Scholar
  62. Sakhuja, S., & Jain, V. (2012). Service supply chain: An integrated conceptual framework. Proceedings of International Conference on Computers and Industrial Engineering, Cape Town, July 16-18.Google Scholar
  63. SAMHSA (2013). Innovations in Addictions Treatment: Addiction Treatment Providers Working With Integrated Primary Care Services. Washington, DC: Center for Integrated Health Solutions, Substance Abuse and Mental Health Services Administration.Google Scholar
  64. SAMHSA (2017). Behavioral Health Treatments and Services. Washington, DC: Substance Abuse and Mental Health Services Administration.Google Scholar
  65. Schuchat, A., Houry, D., & Guy, G.P. (2017). New data on opioid use and prescribing in the United States. JAMA, DOI: Scholar
  66. Schulman, K.A., & Richman, B.D. (2016). Reassessing ACOs and health care reform. Journal of the American Medical Association, 316 (7), 707-708.CrossRefGoogle Scholar
  67. Shortell, S.M., & Casalino, L.P. (2008). Healthcare reform requires accountable care systems. Journal of the American Medical Association, 300 (1), 95-97.CrossRefGoogle Scholar
  68. Sisk, J.E., Hatziandreu, E.J., & Hughes, R. (1990). The effectiveness of treatment for drug abuse. In The Effectiveness of Drug Abuse Treatment (Chapter 4). Washington, DC: Office of Technology Assessment.Google Scholar
  69. Sussman, S., Leventhal, A., Bluthenthal, R.N., Freimuth, M., Forster, M., & Ames, S.L. (2011). A framework for the specificity of addictions. International Journal of Environmental Research and Public Health, 8 (8), 3399-3415.CrossRefGoogle Scholar
  70. Thaler, R.H. & Sunstein, C.R. (2008). Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press.Google Scholar
  71. Topol, E. (2017). The smart-medicine solution to the health care crisis. Wall Street Journal, July 7.Google Scholar
  72. Torous, J. (2017). Digital psychiatry. IEEE Spectrum, July, 44-50.Google Scholar
  73. Vermeulen, I., Bohte, S., Elkhuizen, S., Bakker, P., & La Poutre, H. (2008). Decentralized online scheduling of combination appointment in hospitals. Proceedings of the Eighteenth International Conference on Automated Planning and Scheduling, 372-379.Google Scholar
  74. Voudouris, C., Owusu, G., Dome, R., & Lesaint, D. (Eds). (2008). Service Chain Management. Berlin: Springer.Google Scholar
  75. Wahlbeck, K. (2010). Moving towards integrated addiction treatment systems. Nordic Studies on Alcohol and Drugs, 27, 699-702.CrossRefGoogle Scholar
  76. Walker, E.R., McGee, R.E., & Druss, B.G. (2015). Mortality in mental disorders and global disease burden implications: A systematic review and meta-analysis. JAMA Psychiatry, 72 (4), 334-341.CrossRefGoogle Scholar
  77. Wang, P.S., Berglund, P.A., Olfson, M., & Kessler, R.C. (2004). Delays in initial treatment contact after onset of a mental disorder. Health Services Research, 39 (2), 393-416.CrossRefGoogle Scholar
  78. Wang, Y., Wallace, S.W., Shen, B., & Choi, T-M. (2015). Service supply chain management: A review of operational models. European Journal of Operational Research, 247, 685-698.CrossRefGoogle Scholar
  79. Weisner, C., Mertens, J., & Pathasarathy, S. (2001). Integrating primary medical care with addiction treatment: A randomized control trial. JAMA, 286 (14), 1715-1723.CrossRefGoogle Scholar
  80. Wen, L.S. (2016). A new vision of true health. Consumer Reports, Scholar
  81. White, J.A., Schmidt, W., & Bennett, G.K. (2012). Analysis of Queueing Systems. New York: Elsevier.Google Scholar
  82. Wyman, O. (2014). ACO Update: Accountable Care at a Tipping Point. New York: Oliver Wyman.Google Scholar
  83. Yap, G.L., & Tan, C.L. (2012). The effect of service supply chain management practices on the public healthcare and organizational performance. Journal of Business and Social Science, 3 (16), 216-224.Google Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • William B. Rouse
    • 1
    Email author
  • Kara M. Pepe
    • 2
  • Michael M. E. Johns
    • 2
  1. 1.Center for Complex Systems and EnterprisesStevens Institute of TechnologyHobokenUSA
  2. 2.Schools of Medicine and Public HealthEmory UniversityAtlantaUSA

Personalised recommendations