Population Health Management within the Value Transformation Framework encompasses a systematic process of utilizing data on patient populations to target interventions for better health outcomes at lower cost, with a better care experience.

This Action Guide from NACHC focuses on one foundational component of population health management: risk stratification. Risk stratification enables providers to identify the right level of care and services for distinct subgroups of patients. It is the process of assigning a risk status to a patient and then using this information to direct care and improve overall health outcomes. 

NACHC lays out a straightforward approach including the following steps:

          STEP 1 Compile a list of health center patients

          STEP 2 Sort patients by condition

          STEP 3 Stratify patients to segment the population into target groups based on the number of conditions per patient

          STEP 4 Design care models and target interventions for each risk group

Learn more about what is required for each of these steps and other key concepts, by visiting the Action Guide.