02 — Capability · BC-1860
Population Health
Improve health and lower the cost of care for defined groups of patients or members, by finding who is at risk, managing care between visits, engaging people in their own health, meeting social needs and earning what value-based contracts pay for results. Care within a visit or stay is clinical care delivery.
- Population Health Management
- PHM
- Value-Based Care Operations
In scope
- Attribution, risk stratification and care gap identification
- Care management, disease management and transitions of care programs
- Value-based contract performance, shared savings and risk adjustment accuracy
- Patient and member outreach, and social needs screening and referral
Out of scope
- Care plans and coordination within an episode of care (see BC-1820.30)
- Negotiating fee-for-service payer contracts (see BC-1840.60)
- Experience measurement and loyalty programs in general (see BC-460)
- Health plan review of requested services (see BC-1870.50)
Realized by · 14
- Salesforce · Health Cloudpartial via BC-1860.20.20
- Epic · MyChartcore via BC-1860.40.20
- Epic · Payer-Provider Exchangepartial via BC-1860.10.30
- Epic · Healthy Planetstrong via BC-1860.10.10
- Oracle Health · Health Data Intelligencestrong via BC-1860.10.30
- MEDITECH Expanse · Population Health and Care Compassstrong via BC-1860.10.30
- MEDITECH Expanse · Patient Connect and Patient Portalstrong via BC-1860.40.10
- InterSystems HealthShare · Event Notificationsstrong via BC-1860.20.40
- InterSystems HealthShare · Health Insightpartial via BC-1860.10.20
- InterSystems HealthShare · Care Communitypartial via BC-1860.20.30
- InterSystems HealthShare · Personal Communitypartial via BC-1860.40.20
- HealthEdge · Clinical Edge Care Managementcore via BC-1860.20.10
- HealthEdge · Wellframe Member Engagementstrong via BC-1860.40.10
- HealthEdge · Revenue Align Edgepartial via BC-1860.30.40
Used in · 6
- Enroll-to-Care · 02 Engage via BC-1860.40
- Enroll-to-Care · 03 Assess Risk & Needs via BC-1860.10
- Enroll-to-Care · 04 Connect to Care via BC-1860.10
- Enroll-to-Care · 05 Manage Care via BC-1860.20
- Enroll-to-Care · 06 Measure Outcomes via BC-1860.30
- Claim-to-Payment · 07 Recover & Settle via BC-1860.30
Build it · 0
- Nothing in the library points here yet.
Decomposes into · 5
- BC-1860.10Population Risk & AttributionKnow which patients or members are likely to need more care, cost more or fall through gaps, by combining claims, clinical and social data into attribution, risk tiers and care gap lists that teams can act on. Building predictive models in general is analytics.
- BC-1860.20Care Management ProgramsHelp people with complex, chronic or transitional needs stay well between visits, by enrolling them in care, disease and transition programs, assigning a care manager and following a shared plan with them. Care planning inside a visit or stay is clinical care delivery.
- BC-1860.30Value-Based Care ContractsSucceed under contracts that pay for outcomes and total cost of care rather than volume, by modeling them before signing, tracking performance against benchmarks during the year and reconciling shared savings or losses. Negotiating fee-for-service rates is payer contracting.
- BC-1860.40Patient & Member EngagementKeep patients and members informed and involved in their own health between encounters, through reminders, education, portal access and outreach that closes care gaps, sent the way each person prefers. Brand and general marketing campaigns sit with marketing.
- BC-1860.50Social Needs & Community ResourcesFind the social needs, such as food, housing and transport, that stand between people and good health, connect them with community organizations that can help and close the loop on each referral. Corporate giving and community relations sit with communications.