Three Key Elements for Successful Population Health Management

Examine the foundation of population health management: information-powered clinical decision-making, a primary care-led clinical workforce, and patient engagement and community integration.

Baby Boomers have started enrolling in Medicare. Information and data are increasingly available and portable. Chronic disease incidence is reaching epidemic proportions. And health reform has set a new timeline for change.

These forces are pushing providers past the point of incremental change toward a new business model centered on delivery of comprehensive care and management of total cost risk.


Organizations on the transition path to population health management must prioritize three foundational elements.

Information-powered clinical decision-making

The health care industry is building toward a vision of complete data integration, getting the right systems in place to work with each other. While this is no small feat in itself, the next challenge will be leveraging data to redesign care. Health systems will need to be able to use IT systems to advance clinical outcomes, improve quality, and lower costs.

Ultimately, to achieve competitive advantage in your IT investments, you must be able to use the wealth of information at your disposal to deliver information-powered care to patients in real time. Read more

Primary care-led clinical workforce

Advances in information-driven care will have a profound impact on the clinical workforce. In a data-powered world, the critical skills of the workforce are those that connect most directly to the “laying on of hands” and motivating patients to achieve better outcomes.

Next-generation technology will support providers in advancing clinical care to help establish high-quality, low-cost care pathways. Technology will also allow providers to extend the reach of the workforce. And within care management, technology will play a supporting role as PCPs manage larger clinical teams and patient panels to help improve overall population health. Read more

Patient engagement and community integration

The first two elements focus on competencies the health system needs to develop. The third element shifts the focus outward: how you relate to patients and ultimately your community.

The challenge of becoming a patient-centered enterprise is that people do not want to be patients; providers are outside of the sphere of their day-to-day activities. If you are going to partner with patients in managing their health, you must integrate into their daily lives.

You’ll also need to overcome non-clinical barriers to achieve the best outcomes, integrate patients’ values into the care plan, and communicate continuously with patients to address and bridge care gaps. Finally, you’ll need to integrate community stakeholders who can connect patients with high-value resources, while expanding your reach beyond the clinical care continuum to anchor community health. Read more


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