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Resource Overview

Population Health Management requires aggregating patient data from a number of sources, and conducting analytics and modeling to derive actionable insights that translate to increased patient engagement and improved outcomes.  Resources in this section describe data sources that are available to health centers, how to access and integrate them, and ways to enrich them with patient-provided data through health risk assessments and patient engagement technologies.

Getting and Using PHM and SDH Data

Risk Stratification Approach
HITEQ Center
/ Categories: Population Health, Implementing PHM and SDH, Using Data for PHM and SDH

Risk Stratification Approach

Population Health Management Action Guide from NACHC

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.

Resource Links

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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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