​​​​​​​Achieving Accountable Care

Population Health Management

Standards for care delivery and associated metrics will drive a focus on the quality, efficiency and compliance objectives of the various practice areas. Comparative performance metrics become possible, and the analysis and improvement of clinical, health economic, and strategic financial outcomes enable resources across the diverse care settings and delivery entities to be better aligned.

Organizations pursuing this stage are often seeking to answer key analytical questions such as:

  • How do we Better Integrate and Focus our Care Delivery across these Populations & Care Settings?​

  • How do we Manage Patient Cohorts more Systematically?

The following Action Plans are concrete steps organizations must consider for progressively achieving this stage.

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Action Plans
​Patient Stratification
  • ​Define segmentation attributes and criteria for clinical, operational and/or financial stratification of patient or service delivery outcomes

  • Apply baseline and period performance data to defined strata

  • Examine stratified outcomes against targets and evaluate utility of defined stratification criteria, and performance measures

​Comparative Outcomes & Quality Metrics
  • ​Analyze clinical, operational and financial outcomes and performance against targets of individual physician, clinical team, group or practice, service line or other appropriate entity within the collaborating ACO

  • Allocate savings (or losses) based on ACO collaboration and contractual terms

​Prospective & Bundled Payment Models
  • ​Monitor baseline and period performance to build forecasting capacity to enable tighter controls on future payment models, fee schedules, and contractual terms

  • ​Apply baseline and period performance data to per-patient-per-month or other population-based projections for payments

  • ​Use projections to inform contract terms, fee schedules, and segment investments for prospective performance periods within the planning horizon

Predictive Modeling
  • ​​Apply baseline and period performance data to the development of predictive models correlating outcomes with the key patient, provider, location or ACO entity characteristics or behaviors

  • ​​Perform analytics on predictive value of models, using retrospective analyses of actual performance and outcomes in focused segments and contexts                           

Performance Optimization
  • ​​Measure performance along various segments and implement improvement programs to optimize process execution and resource alignment to drive targeted outcomes

Market Share & Competitive Analytics
  • ​Identify and analyze clinical quality, patient satisfaction and financial performance by market segment

  • Map segment performance based on volumes (and rates), savings (or losses), costs, value stream participants, resource consumption and impacts on outcomes

  • Analyze competitive performance in targeted segments