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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
Rising Risk: An Overview of Identification and Intervention Approaches
HITEQ Center

Rising Risk: An Overview of Identification and Intervention Approaches

A brief from JSI with the support of Blue Shield of California Foundation

This brief, produced with generous support from Blue Shield of California Foundation, explores the concept of rising risk in the health field. Given that it is well understood that the top 5% of patients account for more than 50% of utilization, it follows that identifying risk in the population early and intervening effectively has the potential to save resources and improve health outcomes. The growing emphasis on efficiency and value, a new set of data collection and analysis tools, and the recognition that uncoordinated, after-the-fact response is not optimal all support a focus on rising-risk populations. 

Through a literature review and discussions with leaders in the field, JSI investigated key considerations in addressing rising risk, outlined methods for identification and intervention along a continuum from focusing on one individual at a time to focusing on populations, and identified illustrative examples from the field. 

Download the brief below or access it here.

Documents to download

Previous Article The 2018 Social Determinants of Health Academy
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Intended AudienceHealth Center Staff, Quality Improvement Staff, Health Center Leadership

Acknowledgements

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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