Population Health Management

Hospital Best Practices and Recommended Strategies

The tools and resources below help leaders and providers transition to value-based systems and prepare for population health management.

Findings and Guide from the 2019 Rural Care Coordination and Population Health Management Summit: Explore the findings report from the 2019 Rural Care Coordination and Population Health Management Summit, a short video featuring panelists from the Summit, the webinar playback of the guide and report, and the Rural Hospital Guide to Improving Care Management.

Population Health Planning

Use the Population Health Portal tools to initiate population health planning and navigate next steps toward population health management

  • Perform a Population Health Readiness Assessment to determine readiness and evaluate next steps in the planning process
  • Apply the Get Informed resources to start collecting data, assessing information and establishing workflow and communication processes
  • Learn communication techniques to motivate staff, partners and community to Get Going on initiating the planning process to prepare for population health
  • Apply available resources and Put Data To Use to effectively conduct population health analytics with access to a web-based database for acquiring health data specific to your location. This tool consists of educational modules offering step-by-step instructions of common population health analytical procedures. Users can extract data from multiple federal, publicly available datasets to use for population health planning. The portal also provides educational resources about working with the datasets in Microsoft Excel.

Identify and Manage Populations

  • Apply the techniques in the Guide for Rural Hospitals to Identify Populations and Shift to Population Health to identify key patient populations and learn to integrate population health initiatives as part of an organization’s strategy. Providers will gain a greater understanding of how to determine which patient populations to target in their initiatives and where to direct resources to improve quality and outcomes as well as reduce the cost of care.
  • Use the self-funded employee health plan to learn how to manage population health interventions
  • Use employee claims analysis results to gain experience and build internal analytic capabilities to better understand where opportunities may exist to improve the health of the workforce and improve population health planning and management next steps
  • Use Community Health Status Indicators (CHSI 2015) to help identify key populations
  • Refer to Guide to Selecting Population Health Management Technologies for Rural Care Delivery to learn how to optimize the health of patient populations. The guide focuses on the patient populations of health care delivery organizations rather than broader community-wide initiatives

Position For 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.