Executive Summary

This executive summary analyzes the various patterns of population health management (PHM) that our health system is developing for our diverse population. We have identified four distinct patterns, each of which is tailored to the specific needs of a particular population cohort.

Pattern 1: Early Intervention

This pattern is designed for populations that are at high risk for chronic diseases. We identify these populations using a variety of factors, including age, race, ethnicity, and health status. Once we have identified these populations, we offer them a variety of preventive services, such as screenings, vaccinations, and counseling. We also work with them to develop healthy lifestyle habits.

Pattern 2: Disease Management

This pattern is designed for populations that have already been diagnosed with a chronic disease. We work with these populations to manage their disease and prevent complications. We offer them a variety of services, such as medication management, education, and support groups. We also work with their providers to coordinate their care.

Pattern 3: Care Coordination

This pattern is designed for populations that are facing multiple challenges, such as chronic diseases, social determinants of health, and financial barriers to care. We work with these populations to coordinate their care across multiple settings, such as hospitals, clinics, and community organizations. We also provide them with support services, such as transportation and financial assistance.

Pattern 4: Population Health Analytics

This pattern is designed to help us better understand the health needs of our population and to identify opportunities for improvement. We use a variety of data sources, such as electronic health records, claims data, and surveys, to track the health status of our population. We also use this data to identify populations that are at risk for poor health outcomes.

We believe that these four patterns provide a comprehensive approach to PHM. By tailoring our interventions to the specific needs of each population cohort, we can improve the health of our population and reduce the cost of care.

Discussion

Each of the four patterns described above represents a different way of thinking about PHM. Pattern 1, Early Intervention, is focused on preventing chronic diseases before they develop. Pattern 2, Disease Management, is focused on managing chronic diseases once they have developed. Pattern 3, Care Coordination, is focused on coordinating care across multiple settings for populations that are facing multiple challenges. Pattern 4, Population Health Analytics, is focused on using data to better understand the health needs of our population and to identify opportunities for improvement.

We believe that these four patterns are complementary and that they can be used together to create a comprehensive approach to PHM. By tailoring our interventions to the specific needs of each population cohort, we can improve the health of our population and reduce the cost of care.

Conclusion

We are committed to developing and implementing a comprehensive approach to PHM. We believe that these four patterns provide a foundation for this approach and that they can be used to improve the health of our population and reduce the cost of care.

Recommendations

We recommend that we continue to develop and refine these four patterns. We also recommend that we explore other ways of thinking about PHM and that we adopt new approaches as they become available. We believe that by continuing to innovate, we can improve the health of our population and reduce the cost of care.