• Five percent of Medicare’s patients account for almost 50 percent of its cost. The same 5:50 rule holds true for other insurances.

  • The ongoing changes in health care like Affordable Care Act, Meaningful Use, ICD 10 transition, and Value Based Purchasing has placed acute care hospitals like ours at risk for significant financial loss in the coming years. 

  • These changes are forcing healthcare organizations to innovate in care delivery and provide high quality healthcare to our patients and put additional focus on Population Health Management.

  • In an inner city community hospital like ours, serving poor and minority population, we need to focus not only on medical issues, but also on behavioral, environmental, psychosocial and system based factors to improve health and wellbeing of our patients and decrease resource utilization. At least, half of these factors could be preventable.

  • There several programs like ACO and DSRIP that provide funding to innovate in healthcare.

  • A hospital based Population Health Program offers several advantages like funding, infrastructure, and staffing.

  • We have developed a hospital based program that brings all the personnel, tools, resources, and expertise to provide patient centered, cost effective, efficient, safe, coordinated, and culturally sensitive care to our high utilizer patients.

  • When the patient is admitted to the hospital, we conduct a Comprehensive Community Social Risk Assessment to identify social determinants of poor health and develop new community based programs to mitigate these risks.

  • The goal of the program is to eliminate waste and rework, and decrease PMPM cost by 5% per year. 


  • Provide safe, effective, patient-centered, timely, efficient, and equitable care to our most vulnerable patients, the top 5% utilizers, identified by claims data.
  • Enhance patient safety, quality of life, and quality of care for our most vulnerable population.


  • Increase collaboration and communication between various program attempting to decrease resource utilization, thereby improving patient care and outcomes, and decrease resource utilization. 

  • There is significant amount of work needed to identify and address behavioral, environmental, and social issues in the community to improve the health and wellbeing of these patients.

  • We wish to describe stepwise approach to successfully establishing a hospital based Population Health Management Program, while developing unusual partnerships along the way.  Also, providers don’t have the training and tools to identify and address behavioral, environmental, and social factors affecting overall health of the patients. 
  • The program is based on the principles of explicit delineation of roles and responsibilities with individual and group accountability, continuous process and quality improvement, adoption of best practices in the field of Population Health Management, clear target of decreasing PMPM cost by 5% per year in the intervention group, direct leadership support and guidance with direct reporting to the Executive Director and Chief Medical Officer, use of data in real time to drive changes needed to achieve the target, bringing various programs working to decrease resource utilization under one umbrella, and partnering with community resources to optimize care. 


As we move to value based care, Population Health Management Program like ours can be at the forefront of innovation in Health Care.  Population Health Management could be the next frontier for our Hospital Medicine movement.