Improving population health first requires the clear articulation of the populations for whom care is targeted and their health risks. This session will provide a framework to stratify the population according to their level of risk, conditions, gaps and disparities in care and recommend approaches to using these insights to tailor the intervention.
Define and identify patient population attributable to your system
Stratify level of risk in population (e.g. chronic conditions, repeat ED visits/high LOS, medication non-adherence)
Define data and algorithms needed to determine gaps or variations in care
Employ systems and processes (e.g. registries, alerts to patient/care coordinators, consumer/community education) to translate information into improved outcomes. Measure outcomes and compare against goals