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.