Despite the rise in popularity of population health management since the Affordable Care Act, nearly all providers trying to advance care transformation strategies confront some unchanging challenges:

• An undefined end state that makes it difficult to prioritize across competing goals and population health needs;
• Limited benchmarks, little evidence, and unclear ROI that complicate decision-making; and
• Too many stakeholders, which often results in fragmented program development and can hinder broader system buy-in.