Population Health

Population health management focuses attention on the needs of your entire patient population. Population management tasks vary depending on the type of healthcare setting and may include ensuring that each patient has an assigned physician or care team (empanelment), identifying patients that need extra help (risk stratification), implementing patient care plans, and using data to guide proactive care management.

Clinical Standards for Empanelment
This concise reference tool from the Safety Net Medical Home Initiative defines the roles and tasks associated with empanelment and panel management.

Empanelment Implementation Guide
The Safety Net Medical Home Initiative Empanelment site provides resources to assist providers in assigning patients to panels, assessing practice supply and demand, and using panel data to proactively manage care.

Health IT Playbook – Population Health
The Office of the National Coordinator for Health Information Technology hosts this site covering the use of information technology to support care management, care coordination, patient registries, and other population health management topics.

Implementing a point of care registry
This AMA STEPSforward™ module provides information on building and using patient registries for population health management.

Intensive Primary Care
This AMA STEPSforward™ module guides outpatient providers in proactively addressing the needs of high-risk patients with complex care needs.

Managing Population Health: The Role of the Hospital
This guide, developed by the AMA HPOE initiative, details the rationale, benefits, and steps required for a hospital to implement population health management.

Optimal Panel Size for PCPs
The AMA has developed this detailed and clear approach to determining optimal patient panel size for primary care clinicians.

Panel Management Module
This AMA STEPSforward™ module guides providers through the benefits and processes related to patient empanelment and panel management.

Population Health Management: Hospital Best Practices and Recommended Strategies
This site, hosted by the National Rural Health Resource Center, provides resources for population health management, including information on transitioning to value-based payment sytems.

Population Health Related Quality of Life
The CDC Health Related Quality of Life is a short instrument allowing an organization to assess and compare population metrics from the perspective of patients and community members.

Stratifying Race, Ethnicity and Language Data
The guide, developed by Hospitals in Pursuit of Excellentce, provides a framework that allows hospitals and health care systems to stratify patient data to identify health care disparities, an important aspect of population health management.