1. Define
Population
Population Health Management
1
ID Gaps
in Care
Stratify
Care
Manage
Outcomes
Manage
Care
Engage
Consumer
Ongoing & Automated
• Data Integration
• Analysis
• Reporting
• Communication
Action
The goal of PHM is to keep
a patient population as
healthy as possible,
minimizing the need for
expensive interventions
such as emergency
department visits,
hospitalizations, imaging
tests, and procedures
While PHM focuses
partly on the high-risk
consumers who
generate the majority of
health costs, it
systematically addresses
the preventive and
chronic care needs of all
consumers
Care Delivery Model
• PCP in leadership role
• Consumer activation
• Involvement &
personal
responsibility
• Multi-disciplined care
teams
Consumer Factors
• Medical
• Income
• Education
• Employment
• Social Support
• Culture
• Genetics / Genome
• Physical Environment
• Behavioral