Population health management for your practice

Understanding population health management: A comprehensive guide for athenahealth customers and prospects

Population health management (PHM) is a strategic, data-driven method to improve specific patient groups’ health outcomes by proactively coordinating care. Rather than waiting to treat illness, PHM identifies risks early, closes care gaps, and provides continuous support to help patients maintain better health.

As healthcare shifts toward value-based reimbursement, PHM is key for providers aiming to enhance care quality, streamline workflows, and optimize revenue. It integrates medical, social, and behavioral factors into personalized care, aligning teams to deliver coordinated, patient-centered services.

Population health management software transforms data into actionable insights by coordinating providers, actively engaging patients, and measuring clinical outcomes over time. This proactive, comprehensive approach is reshaping healthcare delivery and is a cornerstone for successful practices today.

By focusing simultaneously on entire populations — such as patients with chronic conditions, those at risk for certain diseases, or specific demographic groups — and individual needs, population health services support improved health outcomes, greater practice efficiency, and sustainable financial performance.

This post supports healthcare organizations in adopting effective population health management strategies that convert data insights into coordinated care, active patient engagement, and measurable outcome improvements.

Why population health management is critical for your practice

Practices often struggle with care gaps, fragmented workflows, and multi-provider coordination, leading to missed opportunities, avoidable hospital visits, and lost revenue under value-based care (VBC).

Population health management tools align care teams around shared goals, fostering timely interventions that close gaps and ensure patients receive preventive and chronic care management when needed.

Financially, population health management analytics tools are vital as reimbursement increasingly ties to quality and cost control. Without effective PHM, practices risk failing benchmarks and losing compensation.

athenahealth population health solutions address these challenges by continuously analyzing clinical and claims data to identify patients overdue for screenings or follow-ups, automating outreach, task assignment, and provider communications to reduce administrative burden, and enabling shared care plans for seamless team collaboration. Real-time performance monitoring supports meeting VBC program targets, helping maximize reimbursement and improve care.

Population health management identifies risks early, closes care gaps, and provides continuous support to help patients maintain better health.

Six key components of effective population health management

Successful PHM relies on core elements that enable practices to move from data to action:

• Data aggregation and analytics combine clinical, claims, and social determinant information to provide comprehensive insights into patient needs and risks.
• Risk stratification segments patients by health risk, allowing prioritization of those requiring the most attention.
• Care coordination ensures providers collaborate effectively across settings to deliver consistent, timely care.
• Patient engagement empowers patients with education, communication tools, and support for active participation in their health.
• Chronic disease and wellness management involves ongoing monitoring and promotion of preventive activities to reduce complications.
• Performance measurement and quality improvement track outcomes and satisfaction to refine care strategies continuously.

Together, these components form a holistic, proactive population health model that advances beyond reactive care.

The role of technology in population health management success

While data and coordinated care form the foundation of PHM, technology transforms these elements into timely, informed actions to drive real improvements. Without the right technological tools, even the best strategies can fall short in efficiently closing care gaps and engaging patients.

Many traditional data-only tools fall short because they lack means to close care gaps, streamline workflows, and engage patients effectively. athenahealth population health management software integrates multiple capabilities:

• Population health platforms unify and analyze clinical records, claims, and social determinants, offering actionable views of patient populations.
• Automated patient outreach handles reminders and appointment scheduling to keep patients on track.
• Care management workflows simplify task assignments and collaboration, while secure data sharing fosters compliant information exchange among providers.

Additionally, telehealth, patient portals, and remote monitoring empower patients to stay engaged and manage health from home, improving adherence and outcomes.

By combining robust analytics with patient engagement and operational tools, athenahealth enables practices to efficiently close care gaps, optimize workflows, and deliver personalized care aligned with PHM goals.

For example, a small medical practice, OnPoint Family Medicine, integrated payer and EHR data and partnered with athenahealth Advisory Services. The practice automated analytics and streamlined quality reporting across dozens of payer contracts. This integration gave clinicians a unified, accurate view of care gaps, enabling targeted patient outreach that led the organization toward a full 5-star Medicare Advantage rating.

Common challenges in implementing population health management and strategies to overcome them

Implementing PHM can be complex, facing obstacles like:

• Data interoperability and quality issues from diverse sources complicate risk stratification and coordination.
• Engaging varied patient populations requires tailored communication to overcome language, literacy, and trust barriers.
• Provider and staff resistance due to workflow changes and technology adoption challenges.
• Addressing social determinants of health (SDOH) is tough with limited resources.
• Financial constraints and regulatory compliance add complexity.

To overcome these, practices can adopt interoperable platforms for better data integration, use multi-language patient engagement tools, provide training and automation to ease workflow adoption, partner with community resources to address SDOH, and select compliant, scalable technology solutions to manage costs and privacy.

These strategies help practices implement PHM smoothly, improving coordination, patient outcomes, and sustainability.

Measuring impact: Outcomes and ROI

Success in PHM is gauged by improvements across several critical areas. Clinically, it is reflected in better chronic disease management, higher compliance with preventive care, and a reduction in hospital admissions. Patient satisfaction plays an equally important role, demonstrated through increased patient engagement and improved experiences throughout their care journey. Financially, success means reduced healthcare utilization, lower costs per patient, and optimized revenue through value-based contracts. Together, these metrics provide a comprehensive picture of the impact and value of effective population health management.

OnPoint projects a 50% reduction in manual effort for quality data management by automating processes with athenaOne®. This efficiency gain allows the repurposing of a full-time employee to focus on advanced quality management, payer contract attribution, and strategic planning.

Getting started with population health management at your practice

Six practical steps set your practice for a successful PHM launch:

1. Assess your current data, coordination, and engagement capabilities to identify gaps.
2. Define clear, focused goals like closing care gaps or meeting VBC requirements.
3. Choose a technology partner that integrates analytics with actionable workflows.
4. Use comprehensive data to prioritize high-risk patients and guide care.
5. Invest in ongoing training to support adoption and maximize program value.
6. Embrace continuous improvement by monitoring outcomes and adapting strategies.

Taking these foundational actions builds a strong PHM framework, enabling proactive, coordinated care that improves outcomes, efficiency, and competitiveness in VBC environments.

Enhance care quality with athenahealth population health services

Population health management represents a fundamental shift toward proactive, coordinated, and patient-centered healthcare. It improves outcomes, boosts operational efficiency, and positions practices for success in VBC.

For providers ready to transform care delivery, athenahealth Population health tools combine insightful analytics with workflow and engagement tools, empowering practices to close care gaps, streamline operations, and enhance patient health sustainably.

Learn more about how athenahealth PHM tools can support your practice’s journey toward improved care quality and financial performance.