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FEATURED CONTENT
Sometimes the success of your population health initiatives is wholly dependent on operational details, such as structured partnership agreements, effective scripting for patient outreach, or risk assessments. We’ve collected care decision guides, scripting, governance documents, tools, risk assessments, and evaluation forms that are critical to the success of operating population health initiatives. This library includes ready-to-use resources you can download and tailor to optimize your initiatives.
We'll continue to update the library with new resources based on discussions with population health leaders across the country.
Looking for job descriptions? Visit the Population Health Job Description Library to download a variety of cross-continuum descriptions for executive, administrative, and frontline roles across care transformation.
Ambulatory care
Inpatient care
- OSF HealthCare Palliative Care Referral Decision Tool
- Kaiser Permanente IP Palliative Care Risk assessment
Post-acute care
- Baystate Medical Center Post-Acute Level of Care Decision Guide
- Rush University Medical Center Home Health Handoff Checklist
- Universal Patient Transfer Form for PAC
- Yale New Haven Medical Respite Eligibility Criteria
Transitional care
Care/case management
Clinical needs
Psychosocial needs
- University of Illinois Hospital and Health Sciences System Psychosocial Risk Assessment
- Vanguard Medical Group Risk Assessment and Care Plan
- Kalispell Regional Medical Center Patient Financial Need Assessment
Community needs
Risk assessment
Process improvement tools
Performance improvement tools
- CentraCare Practice Improvement Idea Card
- Metro Health RN Care Coordinator Performance Dashboard
- Bellin Health System-wide Patient Education Council Charter
Patient education tools
- Children's National Asthma Tips and Reminders
- Scripps Health Diabetes Management Read Food Labels
- Children's National Asthma Action Plan
- Metro Health – University of Michigan Health Care Team
- Renown Health Health Care Summary
- Renown Health Financial Statement
- Adventist Health and Rideout ED Brochure
- Pseudonym'd Tiger Health ED Communication Board
- Pseudonym’d Tiger Health ED Flyer
- Bellin Health Diabetes Zones Patient Tool
Staff education
Patient outreach
Patient education tools
Patient enrollment
- Covenant Care Coordination Patient Enrollment Scripting
- Covenant Patient Enrollment Process and Scripting
- Henry Ford Health System CM Patient Enrollment Letter
- Henry Ford Health System CM Enrollment Phone Script
- MaineGeneral Health System CCM Patient Enrollment Letter
Patient follow up
Referrals
Staff engagement
Performance evaluation
- Jennie Edmundson Hospital SNF Evaluation Form
- Holy Cross Health Network Community Benefit Performance Indicators
- CareFirst PCP Engagement and Quality Scorecard
Readmission root cause
- Cleveland Clinic Readmission Patient Interview
- Carolinas Readmission Patient Interview
- Kaiser South Bay Medical Center Readmission Diagnostic Tool
Investment prioritization
Partnership agreements
- Lehigh Valley Health Network Primary-Specialty Care Partnership Agreement
- Cedars-Sinai Park Housing Partnership Agreement
- JPS Health Network Clinical Practice Agreement
- Maryland Faith Community Health Network Memorandum of Understanding
- Lehigh Valley Health Network Breast Care Management Agreement
- OSF St. Luke Medical Center Pain Treatment Contract
Organizational structure
- Montefiore Community and Population Health Organizational Structure
- Kettering Health Network Care Management Organizational Structure
- Legacy Health Organizational Structure
- Metro Health Organizational Structure
Program definition
Posted on April 14, 2020
Updated on March 17, 2023
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