The Importance of Common Metrics for Community, Social and Population Health

Sep 11, 2018

Improving community health starts with knowing the factors that impact people’s health, both inside and outside of the clinic. Metrics are key to providing a more holistic view of a community’s health, and ultimately inform and drive action. However, decision-makers are often overwhelmed by today’s proliferation of fragmented indicator sets. Without a common, well-understood set of metrics that allow for much-needed community-level comparisons and assessments, healthcare leaders will continue to struggle to achieve a clear picture of community, social and population health.

Why does this matter now?

Social determinants in population health have been gaining momentum and support in the healthcare industry for several decades. Few would dispute that a full, accurate portrait of a community’s health can help residents, community groups, and charitable organizations hone in on problems and launch prevention efforts to improve overall well-being.

The importance of this “full picture” has been recognized and put into practice in a host of healthcare settings. Community health assessments and improvement plans are now prerequisites in a new, voluntary public health department accreditation process. To retain their tax-exempt status, nonprofit hospitals must conduct community health needs assessments every three years and adopt implementation strategies. And the U.S. Centers for Disease Control & Prevention (CDC) now requires health needs assessments for many Community Transformation Grants.

Combined with fiscal realities that often require communities to make the most cost-effective health choices possible, these forces emphasize an increasing need for research and metrics of upstream determinants that can be used to promote health.

How a common set of metrics can help

Focusing on a common set of health status metrics can help improve community health in many ways, including to:

  • Better facilitate comparison across patient populations;
  • Promote collaboration between organizations conducting similar assessments;
  • Improve understanding of what factors truly impact health; and
  • Inspire residents to work together to improve community health

While there is no widely accepted consensus on community and social health metrics, a core set of outcomes from various national, state, and local priorities can help communities get their start. The grid below from U.S. CDC provides a list of the most frequently recommended health outcomes and determinants. After taking a look, let us know:

  • Which metrics are most relevant to your community?
  • What are two things you can do to help move us toward a common set of metrics that improve measurement and outcomes?

Most Frequently Recommended Health Metrics

(from U.S. CDC’s Community Health Assessment for Population Health – linked below)

Healthcare (Access & Quality) Health Behaviors Demographics & Social Environment Physical Environment

Health Insurance Coverage

Provider Rates

Asthma-Related Hospitalization

Tobacco Use/Smoking

Physical Activity


Unsafe Sex

Alcohol Use

Seatbelt Use

Immunization and Screenings





Poverty Level

Educational Attainment

Employment Status

Foreign Born


Language Spoken at Home

Marital Status

Domestic Violence and Child Abuse

Violence and Crime

Social Capital/Social Support

Air Quality

Water Quality


Health Outcomes

Mortality: Leading Cause of Death, Infant Mortality, Injury-related Morality, Motor Vehicle Morality, Suicide, Homicide

Morbidity: Obesity, Low-Birth Weight, Hospital Utilization, Cancer Rates, Motor Vehicle Injury, Overall Health Status, STDs, AID, Tuberculosis


Additional information on recommended health outcome and social determinant metrics is available in the CDC’s Community Health Assessment for Population Health Improvement.

Download the full Community Health Assessment Guide


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