With the shift from fee-for-service to value-based care, population health management is a priority at most healthcare practices. But while many providers agree that it’s crucial, most organizations have a hard time implementing strategic population health management. 

Effective population health management is not as hard as it seems but it does require a thoughtful approach to segmenting and targeting specific patient populations. By grouping patients with like conditions, providers can distribute useful resources and messages that are relevant and personalized to each particular group, using automation to scale communication. 

The first step is to think about which groups need additional care the most. To get you started, here are three ways you can start to segment your patients for effective population health management.


Patients with Specific Chronic Diseases

Chronic disease is expensive and widespread with about half of U.S. adults having at least one chronic disease. That’s why helping chronic patients effectively manage their disease is critical to improving outcomes and lowering costs. 

Consistent and effective communication plays a significant role in increasing adherence to chronic disease management. After all, most patients don’t intend to be “non-compliant”. They simply don’t know how to better manage their chronic condition, or, they experience barriers that prevent them from following their care plans. 

Effective population health management requires engagement with patients, before, during, and after medical appointments. Patients with chronic disease want and need individualized treatment and tools that help them manage their condition outside of the clinical setting. Automated population health outreach makes this possible.

Population health outreach can be tailored for a variety of common chronic conditions, including:

  • Asthma
  • Diabetes
  • Congestive Heart Failure (CHF)
  • Coronary Artery Disease (CAD)
  • Chronic Obstructive Pulmonary Disorder (COPD)
  • High-Risk Obstetrics
  • Mental Health
  • Obesity

Using technology that integrates with your EHR can allow you to easily identify and target patients with specific conditions for tailored population health outreach. For example, in a population health outreach campaign for patients with diabetes, healthcare providers and payors could target patients with HBA1C levels above 8 who have also not been to the doctor in the past 90 days.

Automated technology allows you to send text messages or voice calls customized to a specific patient population. This allows you to communicate clinical resources and education at scale to help patients better understand their care plan and feel empowered to stick to it. Clinical messaging can increase engagement, and when a patient deviates from their care plan, automation can inform the care team, allowing them to intervene in a timely manner.


Patients Demonstrating Risk Factors

In addition to chronic disease, other high-risk patients should be at the top of your priority list when it comes to population health management. In fact, improving outcomes for the top 3 to 5% of high-risk patients at your practice could dramatically increase your practice’s performance, according to the Agency for Healthcare Research and Quality. Providing preventative service options through population health outreach for targeted at-risk groups can help each patient maintain the highest possible quality of life while avoiding crisis events and expensive services.

 Analytical tools and technology can help you sort through various risk factors, including:

  • Advanced age
  • Demographics
  • Diagnoses
  • Economic Status
  • Hereditary Diseases
  • Utilization History

Patients identified as high-risk based on how they rank using the above criteria may benefit from population health management outreach campaigns that provides care plan adherence advice, patient support programs, or social and community follow-up. For example, you may consider targeting high-risk adults between the ages of 55-80 who have used tobacco within the last 15 years by prompting them to schedule lung cancer screenings. Or, perhaps you may use text messaging to encourage them to join smoking cessation programs to lower their risk.


Patients Overdue for Preventative Care

Finally, patients can be segmented by based on when they last received preventative care, including:

  • Annual and wellness visits
  • Cancer screenings (e.g. breast cancer, colorectal cancer, or lung cancer)
  • Immunizations and vaccinations (e.g. flu shots)
  • Prenatal and postnatal care
  • Sports physicals

For example, population health management outreach may include targeting eligible women for annual mammograms, which could be the difference between life and death. Automated and targeted population health outreach can ensure regular screenings stay top of mind for women above 40, which can reduce their risk of breast cancer by 66%.

By proactively connecting parents and patients to the right care, you may be able to minimize unnecessary visits that result from preventable diseases. This improvement in adherence keeps your patients healthier and your costs lower.

Learn more about designing population health outreach at your organization.


Are you ready to improve population health management at your practice? To make the biggest impact without draining resources, start by targeting patients with the most risk. The following questions may help you determine where to start:

  • Who are the high-cost and high-risk patients at our practice today?
  • Which patients demonstrate multiple chronic conditions AND risk factors?
  • Which patients are overdue for care and therefore are rising in risk?

Once you’ve identified WHO needs to be targeted, your population health management strategy may want to consider leveraging technology to communicate with them. The right solution can help filter through this criteria in your EHR and send customized messages based on the individual needs of each segment. 

Automated population health management can help you generate higher engagement with each population group than manual outreach because it allows you to reach the right patients with the right resources. And that means better outcomes for your patients and improved financial success for your practice.

Want more? Discover 6 ways automated population health management can improve quality outcomes.