What is the challenge?

Waiting for patients to come in for visits is an ineffective way to meet their needs with ongoing health problems. For patients with chronic illness, problems are missed or seen late; and when visits do occur, they tend to focus on the urgent, not the chronic. Many patients also fail to receive important preventive services. This creates problems and gaps in care that contribute to poor health outcomes.

What needs to change?

Practices need to regularly review data on clinically important patient populations to identify problems and gaps in care—and then take action to remedy them. This process of reviewing populations, identifying problems, and taking action is called population management. Population management shifts a practice from simply responding to patient-initiated demands to searching for and reaching out to patients needing care. This is both a major culture shift for many practices and unfamiliar work for most staff.

What do we gain by making these changes?

Population management helps keep patients healthier by proactively addressing problems and gaps in care. Many successful practices say that aggressively managing key patient populations is a major reason for their improved performance. Also, the data infrastructure to manage populations is the same as needed to measure performance.

Population Management in Community Mental Health Center-based Health Homes

Managing Populations, Maximizing Technology Population Health Management in the Medical Neighborhood

  1. Link each patient to a specific practice team and provider.

    Before a practice can begin managing patient populations, it must assign each patient to a specific provider and/or team who is responsible for their care. This is sometimes called empanelment. A major benefit of empanelment is that it clarifies clinical accountability. Population management should reinforce continuity of relationships and care, and it is often performed, at least in part, by the MA within a core practice team. 

  2. Decide which patient populations and which data elements to track.

    After empaneling patients, the next step is to select the patient groups the practice wants to manage. Most electronic health records (EHRs) can generate patient basic registries—lists of patients who share selected characteristics, paired with key data elements relevant to their condition and care. Some EHRs can also produce exception reports—lists of patients needing a service.

    Since registries essentially use the same data that are the source for performance measures, the process of deciding who to manage and what to measure is linked. For example, to measure mammography performance one needs the result and date of each woman’s last mammogram. This is the same information needed to identify women who are due for another mammogram or other follow-up. It’s also important to start thinking about assessing the quality and completeness of the data since the practice will need to act on it.

  3. Select and train population management staff.

    LEAP sites implement population management in many different ways. Some sites use centralized staff to review registries and send exception reports to practice teams. Others make time for front office reception staff, MAs and nurses working with individual providers to review registries (or exception reports based on registries), identify patients needing service, and call them. Calling patients to tell them they need more care can be frightening if not done well, so it’s helpful to provide staff with training and scripts.

  4. Develop criteria that specify when to take action.

    For each population and data element, the practice must decide on the criteria for action. For example, if the practice wants to provide better follow up for patients with uncontrolled hypertension, it must specify what it means to be out of control (e.g., blood pressure higher than 140/90 ) and beyond the optimal range for follow-up (e.g., last visit  more than six months ago.)  

ToolkitsImplementation guides and other documents with extensive resources included

  • Toolkits

    Population Management in Community Mental Health Center-based Health Homes

    This resource provides a nice overview and lays out the principles of population management. Although it is written about community mental health-based settings, the material is relevant to taking a population health approach in primary care.

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  • Toolkits

    Managing Populations, Maximizing Technology Population Health Management in the Medical Neighborhood

    Download a guide to taking a population health approach from this website. While focused on Health IT, there is useful information for supporting a team-based approach to population management in primary care, including a case study of one LEAP site, Union Health Center. Shaljian, M. Nielsen, M. Managing Populations, Maximizing Technology: Population Health Management in the Medical Neighborhood. Patient-Centered Primary Care Collaborative (2013)

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WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Exception Report Review Calendar

    See the exception reports used by one LEAP site, the Wright Center-Mid Valley Practice in NE Pennsylvania, as part of relentless efforts to "close the loop" on care gaps.

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  • Workflow

    Population Management Weekly Checklist for MA

    This is a tool developed by one LEAP site to help MAs conduct oureach to diabetic patients on their panel. MAs have four hours of protected time each week to conduct outreach to patients.

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  • Workflow

    Diabetic Population Management Checklist

    This is a tool to help MAs conduct outreach to diabetic patients on their panel developed by one LEAP site. MAs have 4 hours of protected time each week to conduct outreach to patients.

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Staff trainingTutorials, training manuals, etc.

  • Staff training

    Population Management: Managing the Logistics for Your Patient Panel

    See the training materials developed by one LEAP site, West County Health Centers, to support their role in population management. MAs have four hours of protected time each week to conduct outreach to patients. This training helps MAs understand the value of this type of work and tips for calling patients.

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