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What You Need to Know About Population Health Management

Improving health outcomes while reducing costs in primary care

Summary: Population health management is the strategy employed by primary care practices to effectively meet the goals of value-based care. These include improved outcomes, reduced costs, and greater patient and provider satisfaction. Vanguard Health Solutions is the proven regional expert in population health management services. We provide the guidance and tools for primary care practices that are ready to make the transition to population health management.


What if you could harness the information needed to keep your patients healthy for the long term at lower costs? That’s the idea behind population health management. This strategic, data-driven approach elevates primary care to the next level, transforming the health of communities and not just individuals.


Population Health Management Basics


What is population health?


Health develops over a lifetime. Lifestyle, culture, education, income, and even the places we live play a role in our health. By following groups of patients, we can create a comprehensive clinical picture of patient health.


Population health is the study of health status in our communities. It is a data-driven approach designed to fill gaps of care and develop actionable interventions to keep everyone in optimum health.


Importantly, population health is different from public health. Public health describes federal and state government policies and programs to promote better health. Population health seeks to understand the many components that factor into a group’s overall health. This ranges from medical care to lifestyle, genetics, culture, and public health interventions.


What is population health management?


Population health management replaces one-size-fits-all medicine with a customized approach. This approach is based on insights from a group of patients with similar health challenges. It is closely aligned with value-based care, where providers are compensated based on the quality of care that is delivered.


Our team offers the strategies, tools, and resources to help you achieve your metrics in your value-based care contract. You have easy access to your own analytics dashboard to track the metrics needed to achieve your goals.


Benefits of population health management


With population health management, we build strong and sustainable practices by enhancing patient care, quality outcomes, and provider satisfaction. By studying health behaviors, we are able to extrapolate best practices.


We work with our primary care patients in their medical home. We also work within a medical neighborhood, a network of high-quality, cost-conscious specialists, as needed. The benefits of population health management — applying population health to a patient base — include:


  • Improved health outcomes: With preventive care and early interventions, we can minimize risk factors. With a focus on overall health through value-based care, we can significantly improve the health outcomes for our patients.


  • Reduced costs: The optimum path for patient management is the most efficient path toward good health. The preventive care emphasis results in less costly interventions, for overall savings.


  • Increased patient engagement: By partnering with patients in their care, we empower them to take control of their own health. This results in greater patient engagement in the process.


Elements of Population Health Management


Analytics are at the heart of population health management. Not only is it important to review current data and trends, but we can also identify hidden and rising risks through predictive analytics.


Having the right tools to analyze this data is key. Typically, practices use a business intelligence tool to aggregate the data in three areas: clinical, financial, and operational. Such analysis provides real-time insights for data-driven care.


  • Clinical: Providers must look at the continuum of care from patients’ medical homes to specialist, outpatient, inpatient, and ambulatory care settings. This allows you to identify gaps in care to be able to control patients’ chronic conditions more effectively.


  • Financial: Value-based care is closely aligned with population health. By reimbursing positive health outcomes, value-based care rewards practices that follow population health strategies. Value-based care is the future of reimbursement. It is the payment model used by accountable care organizations, such as the Medicare Shared Savings Program.


  • Operational: In population health management, clinically integrated networks share electronic health records (EHRs). This allows seamless communications among providers, laboratories, pharmacies, and inpatient and outpatient settings.


Population Health Management in Your Practice


Population health is a strategic approach to what you are already doing in your practice. It is the addition of intentional and thoughtful oversight coupled with technological tools to bring your patients to optimum health. Following is an example of the practical application of population health management.


  • Identify the types of data that you will use when assessing the health of your patients.


  • Risk-stratify your patients into meaningful categories that go across the continuum of care. Organize them from low to high risk. These different levels will help you allocate resources accordingly. You may wish to set up a comparison group for measurement.


  • Set out the elements of care for this population. This includes preventive care, health risk management, care coordination, disease management, and specialist care coordination.


  • Identify and fill gaps in care. Tap into best practices.


  • Include strategies to engage your patients in their care. Develop a communications plan in which you will reach out to them regularly in a way that they most easily access information.


  • Track patients via EHRs across the continuum of care. Assess regularly and pivot as needed.


  • Measure effectiveness through clinical and health status, patient and provider satisfaction, and financial outcomes. Schedule regular reporting to share with staff involved in the care and payors that require such information.

Why engage Vanguard Health Solutions?


We are your trusted partner in value-based care.


Harness our population health management expertise and analytics dashboard to help you achieve successful value-based care initiatives.


  1. Administrative Management: Risk Coding, Attribution, and Auditing

  2. Network Management: Medical Neighborhood, Specialist Networking, and Referral Management 

  3. Quality Management: Gaps of Care, Quality Metrics, and Chronic Long-term Risk Coordination

  4. High-Risk Management: Transition of Care (TOC), Emergency Department Utilization, and Acute Services

Key Takeaways


Population health management in primary care will:


  • Help identify gaps in care and tap into best practices.

  • Build a medical neighborhood — a network of high-quality, cost-conscious specialists and community partners in care.

  • Expand the focus on preventive care and wellness.

  • Partner with your patients in order to engage them in their own care.

  • Improve clinical outcomes, reduce financial burdens, and increase patient and provider satisfaction.

  • Enable practices to succeed in value-based care.

  • Grow a practice that is sustainable for the future.


See our Services page for more information about Vanguard Health Solutions or request an exploratory call with a VHS specialist today by calling 973.559.3701,  emailing or submitting a form on our contact page.

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