Care Transformation Center Blog

Population health managers, meet the three patient types central to your success


Hamza Hasan

What are the critical components that separate successful population health managers from the pack? Members often ask me this question, and we've found that the answer often lies in the organization's approach to care management.

Population health management is not about managing one population. It’s about managing three—and each requires different goals, resources, and care models.


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Meet your three patient populations


High-risk patients make up the 3-5% of the population that will drive the majority of spending in any given year, and they need more help than primary care can offer.

To create the high-risk patient care team, you must establish a central point of accountability (usually a high-risk care manager), then support these care managers by partnering with external organizations that provide services outside the hospital’s purview. This allows the care manager to craft a truly comprehensive care plan.

Start by understanding why these patients need a one-on-one relationship with the health system, then get four tips for hiring your first high-risk care manager.

Health Care Advisory Board members also have exclusive access to our studies, Playbook for Population Health and High-Risk Patient Care Management, which offer case studies and specific tactics for deploying care managers and investing in wraparound support services. If you're an auditory learner, we've got an on-demand webconference, too.


Rising-risk patients typically represent 20-30% of the population—and in any given year, about 20% of rising-risk patients become high-risk.

To identify these patients, target the risk factors that underlie multiple chronic diseases (ie obesity, smoking, blood pressure, and cholesterol level), rather than the disease states themselves. This enables care managers to target the root causes of multiple conditions.

Then, connect the patients to a primary care practice (typically a medical home) that provides enhanced and coordinated access to care.

Health Care Advisory Board members can learn five strategies for managing rising-risk patients in the medical home by reading our study, Playbook for Population Health. Members can also watch our on-demand webconference.


Roughly 70% of patients fall into the low-risk category, but as we noted earlier this year, nearly everyone is managing well patients wrong.

To build loyalty with patients that have limited in-person interaction with the health system, population health managers must provide convenient access points, alternatives to the ED and physician office, and mechanisms for tracking personal health information.

Health Care Advisory Board members can find out how to accomplish all three goals by reading our study, Playbook for Population Health. Members can also watch our on-demand webconference to learn what you can (and should) do for healthy patients.



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