Playbook for Population Health

Building the High-Performance Care Management Network

Topics: Population Health, Market Trends, Strategy, Chronic Care Management, Methodologies, Performance Improvement, Continuum Integration, Risk Stratification, Care Management, Medical Home, Physician Issues, Primary Care, ACO, Organizational Models, Workforce, Strategic Alignment, Care Transformation, Business Development

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By reading this study, members will learn how to:

  • Build the effective population health management infrastructure
  • Understand how successful population health managers organize their care delivery networks
  • Determine the most effective strategies for scaling care management across a population
  • Redefine access and the point of care for patients at varying risk levels
  • Identify tactics for engaging patients in improving their own health

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  • Health Care Advisory Board members can check out the appendix for care management job descriptions, a list of IT requirements for population management, and more.

Executive Summary

Avoiding pitfalls to population health management

When charting the course to population health management, many organizations fall into the trap of creating a single care model, or focusing solely on high-risk patients. Some also err in segmenting care by payer type, rather than risk profile.

The most successful population health managers don’t build one model for one population. They segment patients by risk level to manage three distinct populations, each requiring different goals, resources, and care delivery models.


Delivering on the vision of population health management

Successful population health managers first define their goals and build a core care management infrastructure that spans the entire patient population.

After defining a strategy and creating a disciplined investment blueprint, they then stratify their patients into smaller, more manageable categories: high-, rising-, and low-risk.

"If you ask 10 people to define care management you’ll get 10 different answers. The key is to standardize the definition of what we expect care management to do." —William Chin, MD, Executive Medical Director, HealthCare Partners

To manage these groups, organizations should:

  • Build an effective population health management infrastructure
  • Connect high-risk patients with a dedicated care management team that coordinates across the continuum to lower total cost of care
  • Manage rising-risk patients in the medical home and develop scalable ways of working with these patients to avoid unnecessary, higher-cost spending
  • Establish easy access to care for low-risk patient management, aiming to keep patients healthy and connected to the system

Committing to Population Health Management