What are the steps to developing a population health management program in your practice?

3 Develop your strategy

The third step is to develop your PHM strategy based on your population needs and your practice capabilities. Your strategy should include your vision, goals, objectives, and action plan for improving the health outcomes and reducing the costs of care for your population. You should also consider your PHM model, such as accountable care organization (ACO), patient-centered medical home (PCMH), or chronic care management (CCM). Your strategy should align with your practice's mission, values, and incentives, as well as with the expectations and requirements of your payers and regulators.

4 Implement your interventions

The fourth step is to implement your PHM interventions according to your strategy and action plan. Your interventions should be evidence-based, patient-centered, and team-based. You should also use a multidisciplinary approach that involves various stakeholders, such as physicians, nurses, care managers, social workers, pharmacists, and community partners. Some examples of PHM interventions are care coordination, care transitions, chronic disease management, preventive care, behavioral health integration, and social determinants of health screening and referral.

5 Measure your outcomes

The fifth step is to measure your PHM outcomes and evaluate your impact on your population's health and your practice's performance. You should use a balanced scorecard that includes clinical, financial, operational, and patient-reported measures. You should also use data from multiple sources, such as EHR, claims, surveys, and feedback. You should monitor your outcomes regularly and compare them with your baseline and benchmarks. You should also report your outcomes to your payers, regulators, and other stakeholders.

6 Improve your processes

The final step is to improve your PHM processes based on your outcomes and feedback. You should use a continuous quality improvement (CQI) framework, such as Plan-Do-Study-Act (PDSA), to identify and address any gaps, issues, or opportunities for improvement. You should also engage your staff, patients, and partners in the improvement process and solicit their input and suggestions. You should celebrate your successes and share your best practices and lessons learned. You should also update your strategy and action plan as needed to adapt to the changing needs and expectations of your population and your practice.