Population Health Management Program


As the healthcare paradigm shifts from treating illness toward preventing illness, providers are being challenged to adopt new models of care delivery and to embrace evolving concepts of value-driven reimbursement strategies. Moreover, healthcare providers must give increased attention to improving healthcare in a manner that improves health outcomes across population groups for the entire nation. For example, data must be collected on populations and assessed to determine the effectiveness of different approaches.

Read the article, Navigating Population Health Management Challenges, for insight into some of the issues that providers face in making the shift toward population health management.

Imagine that you are the new Chief Population Officer for an integrated health system, and you are tasked by your health system CEO with identifying the challenges of such an implementation, analyzing why these challenges exist, discovering research-based proposed solutions for these challenges, and debating the pros and cons of each of these solutions.


Your assignment consists of three parts.

Part 1: Identify Challenges

Identify five of the most significant challenges to implementing a population-health approach for improving health outcomes and promoting wellness in the United States.
Each challenge should be a sub-heading in this part of the paper. Present the challenge, describe it, and provide some history or background, based on credible research sources.

Part 2: Analysis of Challenges

Explain each challenge you identified in Part 1 and provide a comprehensive discussion about why each has broad and far-reaching implications for improving the health of the U.S. population.
Use data and scholarly research to support your thinking and bolster your discussion.

Part 3: Discover Proposed Solutions

Discuss proposed solutions to each of your five identified challenges. These are to be solutions you have found in your research.
Discuss the pros and cons of the solutions you have discovered. What are the arguments for and against these proposed solutions and by whom? This requires critical analysis. You will want to assess the solutions, as well as their detractors and supporters and any possible biases for each. You will want to think through how solutions would be implemented, funded, supported, and received by various stakeholders such as medical professionals, government, and the public.


*The complete paper should address the three parts and to include a title and reference page.
*You must include at least eight credible sources, five of which must be scholarly sources from peer reviewed journals.
*Format your paper according to APA guidelines.



Population Health Management

Population health management is an excellent way of enhancing clinical outcomes, care quality, financial results, and efficiency. Healthcare providers have adopted this technique due to its many benefits. However, it has appeared that there are various challenges in transitioning to this model, with most teams trying to implement the model running into obstacles on staffing and even the development of strategies. This paper will discuss the challenges in implementing a population-health approach and the proposed solutions to improve health outcomes and promote wellness in the United States.

The Five Main Challenges

Identifying the starting point                                

The inability to identify the starting point is mainly due to the growing number of diabetes cases and heart failure cases. This makes most organizations unable to deal with these challenges at once.  Population health is an excellent idea and has great potentials with an unlimited range of possibilities. This makes healthcare organizations find it hard to identify the starting point (Nash et al., 2015). There have been great initiatives in the United States to control diseases like diabetes, obesity, and congestive heart failure. However, most health organizations cannot handle all these challenges together. Therefore, it brings delays before health organizations feature the starting point and how to implement the whole idea.

Understanding the attribution of patients

Patient attribution is an important concept that needs to be emphasized in health care organizations. However, researchers and health care providers continue to show little or no attention to this matter. When it comes to gender, it is evident that most female doctors dislike handling female patients while men mishandle their male counterparts. When it comes to educational background, less educated patients are discriminated against the learned ones (Loeppke et al., 2005). On the matter of age, it is also evident that the health practitioners are more concerned with the young generation than the aged. It has been a challenge to regulate these vices hence affecting the running of health care organizations.  

Stratifying patients by risk

For a long time, stratifying patients by risk has remained a challenge to most health organizations. The main challenge is to establish the attributed population, requiring providers to identify individuals with the highest risk (Edwards & Richardson, 2008). For a long time, healthcare systems in the United States have not been able to buy health IT products for analytics. It is also in the record that there are not enough specialists for risk stratification. For one to do risk stratification efficiently, they must be conversant with data science. They must have access to specific health IT tools to help in the identification of trends and also point out chances for improvement.

Reallocation and Hiring of members of staff

Reallocation and hiring of members of staff are determined by the number of patients to be served. The more number of patients an organization has, the more number of staff it will require. Reallocation is mostly done based on specialty. Specialized health providers are scarce and therefore complicating the reallocation process. There is a great need for staff members required to develop a coordinated care team. Most organizations rely on a staffing structure that is straightforward and centered on support delivery to physicians. However, a population health model is relatively decentralized, with social workers, nurses, behavioral health experts, care managers, and specialists involved in service coordination and achieving goals for specific patients (Novick & Mays, 2005). Therefore, some providers might be required to hire new staff members to develop a coordinated care team.

Developing new workflows acceptance

Health care organizations in the United States are battling to access, maintain, and manage large amounts of data. The organizations lack a well-developed web-based system to administer patients. Due to most clinical procedures’ repetitive nature, workflow management systems are required to automate activities that repeat themselves. The continued ignorance of the relationship between internet technologies, workflow, and health care has also contributed to the challenge of developing new workflows.

Analysis of Challenges

The challenge of where to start occurs due to the many excellent initiatives that organizations can pursue. Some of these areas include diabetes, obesity, and congestive heart failure. Therefore, providers must choose the industry that will save more money and bring out significant improvements without using a lot of effort (Dulai et al., 2018). To deal with the challenge of understanding patients’ attribution, providers must be trained on the need to appreciate all patients regardless of their gender, educational background, or age.  The risk stratification challenge calls for providers to assign the patient with risk scores based on the complexity and number of their chronic illnesses, physiological risk factors, and socioeconomic challenges. Notably, across all reimbursement models, high-risk patients’ stratification has been central to enhancing quality and cost outcomes (Schmittdiel et al., 2017). Health care organizations need to adopt workflow management systems to ease medical data transformation into relevant clinical information. Finally, the challenge of reallocating and hiring members of staff becomes critical when providers are trying to develop a well-coordinated care team and the necessary technology to support it.

Proposed solutions

The solution to the challenge of identifying the starting point, providers need to outline several initiatives that can improve health care. They should then select a cost-effective one and produce the best clinical improvements. For instance, when targeting to increase vaccination rates for pneumonia, health organizations can start with a pilot case. The advantage of starting small is that it will be possible to monitor the vaccine’s effectiveness without causing much harm if it has serious side effects. The disadvantage is that there will be a delay in the realization of the intended outcome. In understanding the attribution of patients, the attribution rules should maximize the number of patients as a way of balancing the ratio of healthy patients to that of high-need patients (Schmittdiel et al., 2017). This method’s advantage is that high-need patients will have a better chance to be served when well implemented. This proposal’s disadvantage is that it may make it practically impossible to manage the turnover rate when the patients become too many. Stratifying patients by risk challenge can be solved using predictive modeling to identify patients at a high risk of poor health proactively. The advantage of this method is that it will help improve the management of risks for those providers that are transitioning to payment based on value. The disadvantage is that it is quite expensive to implement due to the need to buy health IT products. To address developing new workflows, health care organizations should introduce virtual electronic databases for health records. The advantage of this method is that it will ease access to health information for all the patients, while the disadvantage is that the method is expensive and does not guarantee data security. Lastly, the reallocation of staff should be emphasized, and the process for reallocation documented, giving a straightforward procedure of how it ought to be done (Merchant et al., 2016). This proposal’s advantage is that professionals will be psychologically prepared for the reallocations, hence are likely to be more effective in their new destinations. However, this proposal is also disadvantageous in that there is a need to train the new staff, and they might even take time before they adapt to their original task.

In conclusion, population health management is one of the best models that can be used to ensure clinical outcomes, care quality, financial results, and efficiency attained in health care. However, the model faces challenges such as identifying the starting point, understanding patients’ attribution, stratifying Patients by risk, reallocation, hiring staff members, and developing new workflows acceptance. This can, however, be overcome through the proposals mentioned above.


Dulai, P. S., Singh, S., Ohno-Machado, L., & Sandborn, W. J. (2018). Population health management for inflammatory bowel disease. Gastroenterology154(1), 37-45.

Edwards, I., & Richardson, B. (2008). Clinical reasoning and population health: decision making for an emerging paradigm of health care. Physiotherapy Theory and Practice24(3), 183-193.

Hibbard, J. H., Greene, J., Sacks, R. M., Overton, V., & Parrotta, C. (2017). Improving population health management strategies: identifying patients who are more likely to be users of avoidable costly care and those more likely to develop a new chronic disease. Health services research52(4), 1297-1309.

Loeppke, R., Nicholson, S., Taitel, M., Sweeney, M., Haufle, V., & Kessler, R. C. (2008). The impact of an integrated population health enhancement and disease management program on employee health risk, health conditions, and productivity. Population health management11(6), 287-296.

Merchant, R. K., Inamdar, R., & Quade, R. C. (2016). Effectiveness of population health management using the propeller health asthma platform: a randomized clinical trial. The Journal of Allergy and Clinical Immunology: In Practice4(3), 455-463.

Nash, D. B., Fabius, R. J., Skoufalos, A., & Clarke, J. L. (2015). Population health. Jones & Bartlett Publishers.

Novick, L. F., & Mays, G. P. (Eds.). (2005). Public health administration: Principles for population-based management. Jones & Bartlett Learning.

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