Population health is the reflection of your patients
- Identify and engage patients who are at high risk for poor outcomes and unnecessary intervention
- Perform comprehensive health assessments to identify problems that, if addressed through effective interventions, will improve care and reduce the need for expensive services
- Working closely with patients and their caregivers as well primary care, specialty, behavioral health, and social service providers.
- Rapidly and effectively respond to changes in patients' conditions to avoid use of unnecessary services, particularly emergency department visits or hospitalizations
- Show their hospital partner they can do good follow-up care
- Have an integrated system that combines use of risk prediction software, chronic disease criteria, or utilization thresholds with patient/provider referrals or assessments.
- Provides Well-validated system for identifying a subset of high-risk patients
- Provides the most complete picture of expenditures
- Identifies a high-risk population at a time of significant need and opportunity for impact
- Combines the strengths of all the quantitative approaches and brings data together from multiple sources (including qualitative assessments)
- Takes advantage of the strengths of different approaches