Population Health Management

Step 1: Empanel the target population

To achieve effective population health management, providers or care teams must be able to list and locate the patients for whom they are responsible. Thus, empanelment – the assignment of a population of patients to a provider or care team - is a logical starting point and a necessary organizational structure for population health management. ¹ While empanelment can serve as an organizational foundation for effective population health management, it may not be easily implemented in all settings. In these situations, empanelment should remain an aspiration, but other population health management activities can be implemented at the same time.

Populations may be empaneled in a variety of ways, including by geography, voluntary enrollment, or insurance scheme. Ideally, the entire population within a given area should be empaneled to provider teams. This may be difficult or impossible in dense urban areas, areas with large and transient migrant populations, and areas with large numbers of private PHC providers who do not coordinate with a government or larger organizational entity. However, empanelment in mixed public/private PHC systems is possible. ² While a country works towards achieving complete empanelment, stakeholders may choose to start by empaneling certain subgroups of a population with specific health needs.

Step 2: Use panel data to inform local priority setting

After a population is empaneled, providers can shift their focus towards proactive care and health management. Data and registers from the empaneled population can help providers to track the health information of individual patients, plan public health services such as immunization campaigns, and explore indicators of access, utilization, and health outcomes that in turn inform local priority setting. ³ The identified priorities will define the mix of services and medical expertise necessary to manage the patient panel.

Step 3: Based on identified priorities, design systems for outreach in communities and homes

After identifying priority services, decision-makers and implementers can work with communities to determine which services would be most effectively delivered in communities and homes. Often, preventive care or education-based interventions are best suited to community-based care. Ideally, all people would receive proactive care in their communities, but often it may be more feasible to start with specific groups that require special care or attention, such as pregnant women, people with chronic diseases, or children. When planning proactive population outreach, implementers must consider which cadre of provider would most effectively deliver these services based on cost effectiveness, availability, and training. Community members should be consulted throughout the planning process to ensure acceptability of services.