Resource Overview
Population Health Management requires aggregating patient data from a number of sources, and conducting analytics and modeling to derive actionable insights that translate to increased patient engagement and improved outcomes.  Resources in this section describe data sources that are available to health centers, how to access and integrate them, and ways to enrich them with patient-provided data through health risk assessments and patient engagement technologies.
Getting and Using PHM and SDH Data
Risk Stratification Approach

Risk Stratification Approach

Population Health Management Action Guide from NACHC

Population Health Management within the Value Transformation Framework encompasses a systematic process of utilizing data on patient populations to target interventions for better health outcomes at lower cost, with a better care experience.

This Action Guide from NACHC focuses on one foundational component of population health management: risk stratification. Risk stratification enables providers to identify the right level of care and services for distinct subgroups of patients. It is the process of assigning a risk status to a patient and then using this information to direct care and improve overall health outcomes. 

NACHC lays out a straightforward approach including the following steps:

          STEP 1 Compile a list of health center patients

          STEP 2 Sort patients by condition

          STEP 3 Stratify patients to segment the population into target groups based on the number of conditions per patient

          STEP 4 Design care models and target interventions for each risk group

Learn more about what is required for each of these steps and other key concepts, by visiting the Action Guide.

Previous Article Population Health Curriculum
Next Article Integrating Internal and External Data into a Health Center’s Primary Care Services
Please login or register to post comments.

Theme picker


This resource collection was cultivated and developed by the HITEQ team with valuable contributions from the National Association of Community Health centers (NACHC) as well as HITEQ's Advisory Committee and many health centers who have graciously shared their experiences with HITEQ.

Looking for something different or have something you think could assist?

HITEQ works to provide top quality resources, but know your needs can be specific. If you are just not finding the right resource or have a highly explicit need then please use the Request a Resource button below so that we can try to better understand your requirements.

If on the other hand you know of a great resource already or have one that you have developed then please get in touch with us by clicking on the Share a Resource button below. We are always on the hunt for tools that can better server Health Centers.

Request a Resource  Share a Resource
Search HITEQ Content
Highlighted Resources & Events

Theme picker

Need Assistance?
Would you like more assistance regarding Population Health Management and Social Determinants of Health strategies or support in using any of the included resource sets?

  Request Support


The Quadruple Aim
Quadruple Aim

A Conceptual Framework

Improving the U.S. health care system requires four aims: improving the experience of care, improving the health of populations, reducing per capita costs and improving care team well-being. HITEQ Center resources seek to provide content and direction aligned with the goals of the Quadruple Aim

Learn More >