Resource Overview

Population Health Management (PHM) is an evolving concept encompassing a suite of emerging technologies to aggregate, analyze and use data to improve clinical and financial outcomes.  PHM tools enable health centers to identify, monitor and target care to patients within a population. Resources in this section provide a conceptual foundation to help health center staff deepen their understanding of PHM and how the social determinants of health can be used to improve outcomes.

PHM and SDH Concepts and Overview Resources

Population Health Curriculum

From the Robert Graham Center, HealthLandscape, American Board of Family Medicine, and Community Health Center, Inc.

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This curriculum aimed to introduce health care professionals to population health concepts and tools. Resources include slides and note sets, three case studies with sample data, and a performance improvement activity.

Measuring Population Health Management Return on Investment

A methodology to calculate ROI (Return on Investment) using a Matrix Tool

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There is a great deal of interest among health centers, Primary Care Associations (PCAs), and Health Center Controlled Networks (HCCNs) in the advantages associated with investing in Population Health Management electronic platforms. Measuring specific and quantifiable returns clarifies the benefits and supports consistent understanding among stakeholders of the value of PHM.

Empanelment: Defining and Establishing Patient-Provider Relationships

Curated guidance from the Safety Net Medical Home Initiative, AHRQ, Center for Care Innovations, and More

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Empanelment is the basis for population health management and the key to continuity of care. Accepting responsibility for a finite number of patients, instead of the universe of patients seeking care in the practice, allows the provider and care team to focus more directly on the needs of each patient. Inside, find guidance for establishing and maintaining patient panels.

Population Health Management

Concepts for Health Centers

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This is a 4-module PowerPoint presentation is intended as a “backgrounder” for health center staff to introduce the field of population health management. It provides an overview of population health concepts and discusses the role of the social determinants and population health management within the general population. All four modules can be completed by staff to gain a working knowledge of these concepts, implementation directions, creating a cogent and current case for the utility of PHM and SDH, an introduction to data sources and analytics, as well as next steps in the field.

Population Health Management, Social Determinants of Health and How These Fit

The relationship between population health management and social determinants of health

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This is a 21-slide module presenting an introduction to the concept of and relationship between population health management and social determinants of health beginning with current definitions, a brief history of along with the evolution of the field.

Current Population Health Management in Health Centers

The Case for Implementing Population Health Management and Addressing the Social Determinants of Health

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This is a 27-slide module on population health management in the Federally Qualified Health Centers (FQHCs). The module provides several examples of current initiatives that support PHM and SDM as well as the use of these concept in supporting health equity in navigating the Affordable Care Act (ACA).

A Roadmap for Implementing Population Health Management

The implementation of population health management and social determinants of health in healthcare centers

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This is a 22-slide module on the implementation of population health management and social determinants of health in healthcare centers using the framework of the Institute for Healthcare Improvement (IHI) for health equity.

The Power of Social Determinants in Proactive Population Health Management Webinar

A webinar provided by i2i Systems

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This webinar was created by i2i Systems, ranked by KLAS as an early leader among population health management technology vendors. The webinar is hosted by Nancy Thompson, Director of Education at i2i Systems, and presenters are Chris Esperson, MSPH, Quality Consultant and Sonia Tucker, QI Director, LaMaestra Community Health Center.


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This resource collection was cultivated and developed by the HITEQ team with valuable contributions from the National Association of Community Health centers (NACHC) as well as HITEQ's Advisory Committee and many health centers who have graciously shared their experiences with HITEQ.

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The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

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