How Do You Design Population Health Management Tools to Address High-Risk Populations?

Each month, Population Health News asks a panel of industry experts to discuss a topic suggested by a subscriber. Activate Healthcare's CMO Dr. David Claud was featured in the Thought Leaders Corner portion of Population Health News, October 2017. 


Question: How Do You Design Population Health Management Tools to Address High-Risk Populations?

Answer: Programs designed to successfully improve a population’s health must have clearly defined outcomes, straightforward implementation and organization-wide support. Ideally, efforts to manage any defined group’s health—whether high risk, low risk or somewhere in between—should arm patients with knowledge, tools and confidence to manage their care appropriately. Patients who understand their care plan and feel empowered to make positive changes will be more successful at achieving desired outcomes.

When designing population health management programs, it’s important to:

  1. Start with success metrics that matter for your target population. Though well-designed, standard processes often support the achievement of clinical goals, a population’s achievement of certain desired clinical outcomes, such as meeting HbA1c goals, is most directly beneficial.
  2. Develop a workflow within your organization the entire team can support. Team collaboration, from informatics directors to scheduling assistants and many contributors in between, is critical to ensuring effective rollout of these tools. Making resources, such as problem lists or care guidelines, readily available and easily accessible by providers and support staff increases usage and effectiveness.
  3. Draw on available data and analytics, such as “days since last appointment,” to track how regularly patients are receiving care. Missed appointments should trigger a notification to follow up with a patient to determine the cause and offer any additional support.

Every interaction with a patient—whether call, email or office visit— provides an opportunity to engage with patients, show that their providers care about their health and arm them with tools to make improvements.


David Claud, M.D., Ph.D., National Chief Medical Officer, Activate Healthcare, Indianapolis, Ind.



Distributed with Permission.  Published by Health Policy Publishing, LLC, 209.577.4888,

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