Population health management (PHM) encompasses a suite of new and increasingly relevant technologies that enable health centers to effectively assess the health of the population and manage improvement. PHM technologies target the triple aim of improving patient experience and outcomes, and reducing costs. These include analytics tools that help health centers collect and aggregate data on patient populations to drive, evaluate and improve interventions. Patient engagement and care management tools facilitate interaction with patients and support cost-effective decisions that improve patient and population health. Emerging PHM technologies incorporate a focus on the social determinants of health (SDH) – the health-related social circumstances and environmental factors that are thought to contribute half of the modifiable factors that influence health and wellbeing outcomes. Incorporating an emphasis on SDH helps health centers address the contributors to many health conditions; encourages collaboration and coordination across health and social services sectors; and helps remove barriers to consumers’ positive health behaviors and engagement in care. PHM and SDH technologies empower health centers to bear risk for population health as they move from fee for service to adopt value based payment models.

There are many challenges to health centers’ adopting and deriving maximum efficiency and effectiveness of PHM and SDH technologies. Health centers’ resources are limited and face complex quality, regulatory and financial requirements that must be met simultaneously. Identifying, accessing, aggregating and using the right data to inform PHM and SDH is a challenge. There is a myriad of PHM and SDH vendors and tools emerging in the market with varying functionality and comprehensiveness, complex implementation requirements and, often, high price tags. Health centers need to know where to start with PHM and SDH, and how to best apply their limited resources to maximally improve the health of the population.

Integrating and implementing PHM and SDH technologies will help health centers better target and manage patient care, assume and manage their risk associated with cost and outcomes, adopt value based payment models, and improve the health of the population they serve. This collection of resources is organized in answer health centers’ questions about the what, why and how of PHM and SDH. Resources define and describe the concepts of PHM and SDH, and provide an overview of what functionality is available and being used by health centers. We explain the relevance and value of PHM and SDH to health centers, and provide issue briefs describing the intersection of these technologies with EHR, HIE, patient engagement, quality and value based payment. “How-to” information and case studies will help health centers think about and plan their adoption of PHM and SDH tools. We will address the many questions that health centers have about how to identify and integrate available sources of data to PHM tools, and how to collect, access and use SDH data for PHM purposes. To help health centers utilize PHM and SDH to address the triple aim, resources are provided that focus on using these tools to improve quality and value.