Successfully improving population health begins with improving the health of people in the community. This begins with giving health care providers the means to identify and prioritize the individuals in need of help. The first step is to define a standard risk-stratification process by which providers will identify and at-risk populations and disease conditions. For example, EHR data combined with claims data could reveal that a provider has a high concentration of asthma, COPD and lung cancer sufferers living within their service area. Once the population is stratified, providers would evaluate the information from both a population level and an individual level.

• Population-level management—Evaluate whether provider would benefit from implementing care management and disease management programs for identified diseases and populations; these programs should incorporate evidence-based medicine care protocols and the appropriate services, tools and technology
• Individual-level management—Identify individuals within the population to find the riskiest patients; included in this stratification are the risk factors, total costs, inpatient costs, pharmacy costs, outpatient costs and probability of inpatient stay

The next step is to create a comprehensive program focused on medically fragile and high-risk populations. Providers developing such programs should use multiple methods for outreach and standard evidence-based protocols. Organizations that create such programs, especially large organizations, need to develop standard criteria to make sure that patients identified as high-risk are done so consistently across the organization. As patients are identified, new care-delivery standards and processes that support all individuals who interact with the patient should be developed.

The next installment will discuss how care management should focus on populations at various stages of risk.