Population Health Management Concepts

The health outcomes of a group of individuals, often defined by geographic location or shared characteristics.

Focuses on preventing health problems within a population by targeting high-risk individuals.

A set of factors that influence an individual's health, including social, economic, and environmental conditions.

The art of prevention within a population health framework, focusing on social, cultural, environmental, and physical conditions.

A systematic approach to understanding the needs of patients, engaging relevant partners, and designing effective systems to improve health outcomes.

A structured process for collecting and analyzing data to understand a population's health needs.

The ability to access and use reliable data to inform population health strategies.

Engaging community members in the development and implementation of population health initiatives.

A team of healthcare professionals working together to provide coordinated care.

The process of managing the health of a group of patients with similar needs.

A set of 4 recommendations from the National Committee for Quality Assurance (NCQA) designed to guide the implementation of Population Health Management (PHM).

This refers to the process of aligning goals and strategies across different departments or levels within an organization to effectively implement PHM.

This refers to providing healthcare services in a way that ensures everyone has fair and equal access to quality care regardless of their background.

This principle emphasizes the use of data to identify and address disparities in health outcomes.

This principle emphasizes the importance of partnerships between healthcare providers, community organizations, and patients to improve health outcomes.

A healthcare system that prioritizes value over volume, focusing on delivering high-quality, efficient care while reducing costs.

A payment model where providers are financially rewarded based on the quality of care they deliver and the health outcomes achieved.

This involves the patient actively participating in decision-making about their care and health goals.

A healthcare model that shifts from traditional fee-for-service to value-based models, prioritizing quality and efficiency over quantity.

The health outcomes of a group of individuals with shared characteristics, like a geographic region or those with specific health conditions.

A systematic approach to understanding patient needs, engaging partners, and designing effective systems to improve health outcomes within a population.

The ability to access and use reliable data to inform population health strategies. It is a critical foundation for making informed decisions about improving health outcomes.

The process of managing the health of a group of patients with similar needs. This involves identifying those with similar conditions, tracking their progress, and delivering tailored care.

The ability to accurately assess and prioritize patients based on their risk of developing health complications.

A set of factors that influence an individual's health, including social, economic, and environmental conditions. These factors can have a major impact on population health outcomes.

Engaging community members in the development and implementation of population health initiatives. This ensures that programs meet the needs and preferences of the local population.

A team of healthcare professionals working together to provide coordinated care. This can include doctors, nurses, pharmacists, and social workers working collaboratively to improve patient outcomes.

Providing healthcare services in a way that ensures everyone has fair and equal access to quality care regardless of their background.

A structured process for collecting and analyzing data to understand a population's health needs. It involves reviewing existing data, seeking insights from healthcare teams, and conducting additional research.

This refers to the seamless coordination of care across different providers and settings to ensure continuous, high-quality care for patients. It aims to prevent fragmented care and improve overall patient experience.

PHM strategies focus on addressing factors outside of traditional healthcare, including the social, economic, and environmental conditions that influence health. It aims to create a healthier environment for everyone.

Improving health equity in PHM involves ensuring that everyone has equal access to quality healthcare, regardless of their background or socio-economic status. It aims to eliminate health disparities and ensure fairness in healthcare delivery.