Population Health Management eBook

Population Health Management

Growth of Population Health Management Jobs

In the previous chapter, we described how technology-enabled population health management (PHM) is helping level the playing field for healthcare organizations trying to deliver optimal care while improving financial performance. As such, job roles have changed within healthcare organizations as the demand for technologically-skilled nurses and other clinicians have increased.

New Roles Emerging

When PHM was starting to emerge, the care/case manager, often a nurse by training, was primarily responsible for forming and executing strategies, as well as day-to-day operations. As PHM demands increased and technology improved, new executive leadership positions have emerged to lead strategic direction and guide PHM operations. Care managers have maintained their daily data analysis and patient outreach responsibilities, but may now have new titles, such as Population Health Coordinator, Population Health Analyst or Population Health Specialist. During this shift, several PHM leadership roles have emerged, with varying titles and duties. They include:

Chief Transformation Officer (CTO)

A senior executive position with many other duties than PHM, the chief transformation officer is charged with helping transition the organization from fee-for-service, acute, episodic-focused care to holistic, preventive and value-based care. With a background as a physician or advanced-training nurse, the CTO would likely have a long track record of driving change among colleagues at large, integrated healthcare organizations. They would also have extensive experience and knowledge with risk stratification methods and advanced information technology (IT) platforms that would guide how these processes and technologies should be implemented to improve outcomes.

Chief Population Health Officer

Leading population health management strategy, implementation, and oversight at the organization, this senior-executive position needs to stay ahead of PHM trends and collaborate with payers, physicians, other clinicians and IT staff to establish best practices. This leader would most likely be a physician who has public health or administration training with deep knowledge of how advanced data analytic platforms can optimize PHM and outcomes.

Director of Popuation Health

Similar to the Chief Population Health Officer, the Director of Population Health, however, may be more tightly focused on PHM operations in their job duties. They are charged with developing, overseeing and improving PHM programs at the organization. As with the other senior-executive positions, this role is highly collaborative, working with physicians and care managers, but also IT staff, finance, and payers to ensure PHM receives the resources it needs to improve outcomes.

Population Health Manager

This position offers day-to-day support for the primary care and other outpatient facilities to ensure optimal continuity of care chronic condition management among high-risk patients. Likely a registered nurse by training, the population health manager would offer reports and other insight from the healthcare organization's PHM platform to help the care manager or practice improve quality and cost performance. This role would also conduct direct outreach to patients to help them adhere to care plans and overcome obstacles

Adding these positions to an organization will greatly depend on its size, care-quality, patient satisfaction strategy and cost goals. A smaller organization, for example, may only require a population health manager to support the daily operations of its outpatient facilities and would devote less time to strategy and payer relations. Larger organizations will likely require a senior executive focused solely on PHM to educate and tightly integrate clinicians, administrators and staff across the enterprise around those goals.

Whether large or small, PHM platform selection is crucial. The solution must improve the efficiency of data capture and analysis, but also automate interventions to further save time for the care managers and other clinicians contacting patients.

“Whether large or small, PHM platform selection is crucial… It must improve the efficiency of data capture and analysis, but also automate interventions to save time for the care managers and other clinicians contacting patients.”

Larger Enterprises Focus On Readmissions And Outpatient Support

While PHM roles are universally expanding, daily tasks and objectives often differ between larger, integrated health systems and smaller group or individual practices.

Often broader organizations have a staff of PHM care or case managers who have three primary daily objectives to support larger care-quality goals:


Prevent Readmissions

Prevent readmissions of recently discharged patients


Avoid ED Visits

Help patients avoid an unnecessary emergency department visit


Manage High-Risk Patients

Support integrated primary care and specialty outpatient clinics in managing high-risk patients

Compared to smaller organizations, these PHM professionals frequently have greater care access flexibility for high-risk patients, such as finding available appointments with providers within their network. However, to provide relevant and accurate guidance to patients and community physicians, these care managers require access to real-time data and insight through the PHM platform. This means databases need to be continually updated and integrated throughout the enterprise across numerous EHR and other information systems.

Ambulatory Organizations Require Greater Automation

Within independent practices, the care manager charged with PHM may work alone or have limited staff. Practices need their technology to reduce the labor-intensive data searching and patient communication with lower-risk patients so care managers can focus more of their limited time on higher-risk patients to help them overcome care plan adherence obstacles.

For these types of facilities, a highly automated and intelligent PHM technology platform is critical. The technology needs to continually scan multiple databases that help practices stratify their patient population risk levels and offer reliable guidance to care managers on interventions. Automated electronic or phone outreach and communication further reduces that care manager's daily workload.

Regardless of an organization's size, PHM technology is changing how care is delivered and is helping this new breed of tech-savvy senior executives and clinicians perform at their best. Instant, reliable insights based on analysis of up-to-date, comprehensive aggregated data support PHM leaders in developing effective, long-range strategies and objectives while daily helping patient-facing care managers improve the outcomes of individual patients. Across the enterprise or practice, PHM-focused employees can have a wholly integrated single-point-of-truth to identify trends, guide decisions and deliver timely, effective interventions.

The next chapter of this eBook will further explore how real-time, comprehensive data is essential to effective and efficient population health management.
InteliChart Chapter 1

How PHM is changing clinical roles to produce better outcomes.

Chapter 3 InteliChart

Importance of up-to-date, aggragated data is to reliable PHM analysis.