We have the resources to help you identify segments of the patient population most in need, so you can enhance care, improve outcomes, and minimize costs through population health management.
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4 steps to population health management
Identify
- Risk stratification
- Disease registries
- Cohorts
- High utilizers/high costs
- Open care gaps
Assign
- Empanelment
- Coordinate care
- Close care gaps
- Team-based care
- Care plan creation
Engage
- Build relationships
- Educate and activate
- Collect patient-reported data
- Ongoing care management
- Annual wellness visits
Measure
- Baseline metrics
- Set goals
- Monitor
- Assess results
- Improve
We understand the challenges you face
“Having quality measures to show providers is a huge advantage. Once you have the data, you can show them what’s happening.”
Brittani Anderson, care coordinator
North Ottawa Community Health System
Discover more population health resources in our Knowledge Center
