Population Health Management

High-Impact Change: Population Health Management

Population health management lies at the core of the PCMH model. It requires practices to regard patients as individuals and as members of a population. Doing so allows a practice to identify the pressing and pending health needs of its patient population, and determine how best to prevent or meet those needs. Population health management involves a proactive, team-based approach to care that focuses on prevention, early intervention, and close partnerships with patients to tightly manage chronic conditions.

Population health management enables a practice to more easily:

  • Proactively identify patients who need evidence-based chronic or preventive care using health data collected and stored in patient registries.
  • Provide planned care and outreach based on patient diseases or conditions.
  • Provide patient self-management support.
  • Monitor patient progress, identify appropriate care plans, and recommend changes to care plans by including prompts in the electronic health record.
  • Monitor practice performance by tracking patient data and comparing it with national guidelines or internal benchmarks.

PCMH Planner

Population Health Management with the PCMH Planner

Purchase the PCMH Planner for detailed information on how to implement population health management in your practice.

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Be Proactive for Your Patients

Watch the archived version of a webinar demonstrating how the proactive use of data can help you better manage your patient panel.

Amy Mullins, MD, demonstrates the importance of effective population health management in the evolving health care environment using the PCMH Planner.