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How Care Management Supports Population Health at Your Practice

Population health focuses on improving the health outcomes of a specific group of individuals: such as people from the same geographic area, people who share the same diagnosis, or people of similar socioeconomic status. But determining what care a specific population needs, providing that care, and tracking the results is difficult.

To address the specific population health needs of Medicare patients, CMS has proposed multiple care management programs, including Chronic Care Management (CCM) and Advanced Primary Care Management (APCM). These programs align with many of the goals of population health: adjusting interventions based on patient data, emphasizing Social Determinants of Health (SDOH), and evaluating the results of each program.

Keep reading to discover why population health is so critical to Medicare, what makes a population health initiative effective, and how you can improve your population health efforts through care management programs.

Public Health and Population Health

The World Health Organization (WHO) defines public health as a health effort that "provides maximum benefit for the largest number of people."

Population health is closely related to public health, but instead of emphasizing efforts that address as many people as possible, population health focuses on groups of people that share common characteristics. Public health efforts might emphasize laws against smoking in public, while a population health effort might look at how to lower smoking rates in rural communities, specifically. 

Population health considers an array of factors that impact the health of specific groups, from Social Determinants of Health like access to education, healthy food, and safe housing, to behavioral changes and comorbid health conditions. Population health efforts also rely on accurate data, both to determine which patients share characteristics and to measure the results of initiatives directed at those patients.

Because they emphasize SDOH and rely heavily on data, population health programs are effective for an array of patients. But the need to gather and analyze data, connect patients with community resources, and regularly check in on patient progress also makes population health time-consuming, complex, and expensive for practices who are already overworked.

To address these challenges, CMS has created multiple care management programs that encourage practices to focus on population health while reimbursing them for their efforts. The most effective of these is Chronic Care Management, launched in 2015, while the newest is Advanced Primary Care Management, proposed for 2025. 

The Role of Data Analytics in Population Health

Data analytics give healthcare professionals valuable insights into the health needs of specific populations. Based on this data, clinicians can determine which groups of patients need specific interventions, design those interventions, and evaluate whether the interventions were effective.

Because designing effective interventions is such an important element of value-based care, care management programs have long incorporated data analysis. For example, CMS created Chronic Care Management because data showed that Medicare patients with multiple chronic conditions were at greater risk of worsening health. 

CCM offers that specific population of patients care plans, care goals, and monthly support from a dedicated clinician, in an attempt to improve their overall health outcomes and prevent them from worsening. This targeted, data-based approach has worked: CCM has been shown to reduce 30-day hospital readmissions by 52% and emergency department visits by 19% for its enrolled population. 

The Future of Data Analytics

But data analysis is now becoming even more essential to population health efforts. CMS’s new proposed program, Advanced Primary Care Management, requires that patients be stratified–and continually re-stratified–into groups based on their risk level: 

• Level 1: Patients with one or fewer chronic conditions. Will likely require less-frequent care.
• Level 2: Patients with two or more chronic conditions. Generally require more support than Tier 1 patients.
• Level 3: Qualified Medicare Beneficiaries who have two or more chronic conditions. Require the most support, especially when it comes to Social Determinants of Health. 

Once patients have been assigned to a tier, providers and staff can use their clinical expertise to determine what types of care patients need and how frequently they receive it.

CMS’s decision to place Qualified Medicare Beneficiaries in a separate category, with the highest level of support, demonstrates how addressing socioeconomic needs is just as important as data analysis for the population health movement. 

Population Health, SDOH and Care Management

Social Determinants of Health, like safe, clean housing, access to nutritious food, and reliable transportation can have a tremendous impact on population health. If patients don’t have safe places to sleep or exercise, can’t afford to buy healthy food or medications, or don’t have a way to reach their appointments, their chronic conditions are likely to worsen, potentially leading to emergency room visits or hospitalization. 

Population health efforts must therefore incorporate ongoing, community-based SDOH support. Care management programs, like Chronic Care Management, can help. 

Overworked staff at small practices, Rural Health Clinics or Federally Qualified Health Centers may not have time to perform Social Determinant of Health assessments during regularly scheduled appointments. Because CCM care managers check in with patients frequently, they can perform SDOH assessments more easily.

If an assessment shows the patient has unfulfilled SDOH needs, the care manager can direct them to local resources, like housing agencies, food pantries, free exercise classes, volunteering opportunities, or support groups. Care managers can also assist with finding transportation for appointments, arranging medication delivery, or finding support for caregivers. 

New Care Management Programs and SDOH

While programs like CCM have long incorporated Social Determinants of Health, new programs like Advanced Primary Care Management are also embracing SDOH. In addition to providing a tier of additional support for Qualified Medicare Beneficiaries, APCM has Practitioner, Home- and Community-Based Care Coordination as a required component.

Care managers must engage with community-based services and social service agencies when appropriate, as well as help patients transition to and from hospitals and skilled nursing facilities. Care managers must also account for patients’ psychosocial needs and cultural preferences when helping them with care plans and care goals–an important component of making health more equitable. 

Improving Quality Measures with Population Health

To determine whether population health efforts are working, health systems and practices need methods to evaluate their success. One method of measuring success is quality measures.

CMS encourages providers who serve Medicare patients to measure success through a range of suggested quality measures. Different quality programs, like MIPS, MIPS Value Pathways, and ACOs, focus on different measures, from Controlling High Blood Pressure to Screening for Depression, Advanced Care Plan, Adult Immunization Status, and more.

Care management programs can help close care gaps and improve performance on quality measures. When setting up a care management program, practices and health systems can share which quality measures are most valuable for them. Care managers will then check to see which patients need support with those quality measures, whether that means offering tips on measuring blood pressure or setting up appointments for vaccinations.

When the care gaps are closed, practices and health systems will see tangible improvements in their quality scores that show their population health efforts are working. 

Moving Forward with Care Management and Population Health

By addressing Social Determinants of Health and leveraging data analytics, population health initiatives can help the most vulnerable patient communities improve their health outcomes. Care management programs, such as APCM and CCM, play a vital role in population health efforts by ensuring that Medicare patients receive ongoing care. Through care management, dedicated clinicians can gain an understanding of patients’ full spectrum of needs, from their medical conditions, medications, and recent hospitalizations to their socioeconomic needs that require support. If you would like to learn more about how care management programs support population health efforts, check out our article on how health equity intersects with SDOH and Chronic Care Management.