Population Health Readiness Assessment

The primary goal of this assessment is to connect users with tools and resources targeted towards their rural health organizations’ unique strengths and needs for transitioning towards population health through each milestone of Getting Motivated, Getting Informed, and Getting Going. Users are encouraged to complete the assessment multiple times to monitor progress and receive updated resources to guide the journey towards population health.

Please indicate your organization's level of engagement in the critical success factors needed to transition towards population health on a scale of: High, Moderate or Low. If you have not yet started on this success factor, please indicate N/A.

Readiness Assessment
I am aware of the critical role of population health in value-based reimbursement models. *
Board members, senior leadership, medical staff and mid-level managers understand the critical role of population health in value-based reimbursement models. *
The board and leadership team are focused on creating a culture change towards providing wellness care in addition to illness care. *
The board and leadership team support the organization's population health strategies.
The board, leadership team and medical staff can communicate the organization's vision and strategies for transitioning to population health to all staff.
My organization educates patients, partners and the community on the organization's vision and strategies for population health through various modes, including social media.
My organization participates in a community health assessment process to identify health strengths and needs that best serve the people in the community. *
Staff receives ongoing education and support for effectively engaging multiple community stakeholders to coordinate transitions of care aimed at reducing re-admissions and improving wellness. *
Staff coordinates care with multiple stakeholders to address a patient's underlying needs and social determinants of health. *
Staff is educated on Electronic Health Record capabilities for managing population health.
My organization analyzes data (actuarial, clinical, HCAHPS, etc.) to improve patient care and efficiency.
My organization engages in an ongoing cycle of performance improvement based on data collected for improving the health and quality of care.
Staff performs operational, clinical and business processes as efficiently as possible.
Staff utilizes health information technology (electronic health records, health information exchanges and tele-medicine) to manage care effectively.
My organization operates multi-disciplinary care coordination teams that work at the top of their licenses.
Board and leadership offer ongoing staff education on how to provide safe, high quality, person-centered care.
Board and leadership support a staff culture that is adaptable in the change towards prevention and chronic disease management.
Staff role models wellness.
My organization publicly reports all quality and community health needs outcomes.
My organization collaborates with multiple stakeholders and payers to identify shared savings opportunities.
My organization participates in private payer contracts and Centers for Medicare & Medicaid Services (CMS) shared savings models.
Results Delivery
Please complete the following to receive assessment results and a list of tools and resources that will guide you towards population health.

This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number UB1RH24206, Information Services to Rural Hospital Flexibility Program Grantees, $1,560,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.