Population Health Management

Health management is a critical component of social development, and while the objectives of this type management can vary from organization to organization, we tend to revolve around improving patient self-management, improving medication management, and reducing the cost of care – such as admit rates.
Aptuso approach to Population Health Management (PHM) is provider-facing, cost-effective and draws on the data you already have.


In recent years national regulations and customer needs have encouraged us to think differently about how we deliver care. These new regulations and needs focus on cost containment, specifically keeping health care costs at or below prudential public and individual budget. Addressing health care cost growth is important because
it’s crowding out spending in other important areas.


We were deploying new models of care to reduce the growth of health care costs and improve care, but this new contracting environment has accelerated our efforts. PHM is the name of strategy for fulfilling our commitment to improving care and reducing health care costs. Population Health Management (PHM) seeks to improve the health outcomes of a group by monitoring and identifying individual patients within that group. Aptuso PHM programs use a business intelligence (BI) tool to aggregate data and provide a comprehensive clinical picture of each patient. Using that data, providers can track, and hopefully improve, clinical outcomes while lowering costs.

Population Health Management also is a collection of activities, not reimbursable in the feefor-service model, but important in the care we deliver to our patients. We provide the resources and technology for our institutional clients and community clinics to implement PHM across all phases of care and have organized our activities into five key areas, outlined below:


  1. Primary Care - supporting primary care practices in practice redesign (patient-centered medical home) and coordination of care for patients with complex care needs (integrated Care Management Program);
  2. Specialty Care - improving care coordination between Primary Care and Specialty practices and enhancing access to specialty services;
  3. Non-Hospital Care - providing home-based care for patients with acute illness and developing innovative services to better manage transitions of care (among nursing facilities, hospital, and home);
  4. Patient Engagement - offering providers and patients tools to improve communication, education, and patient self-care;
  5. Analytics and Technology - creating a single, centralized EHR/EMR with decision-support tools and a data warehouse for analytics and performance reporting.

What is the core technical model that stays behind

  • analytical tools that aggregate and segment population level data, to give an accurate picture of the population being served and enable outcomes to be tracked
  • electronic health registries with unique patient identifiers (using data from EHRs and other clinical systems)
  • integrating analytics and interoperable IT (including EHRs) across the defined population
  • using financial modelling tools to assess fund flows and pay for health outcomes, which also promote ambulatory care
  • data visualization tools to help coordinate care across the patient pathway and provide dashboards for clinicians to identify and monitor high-risk patients
  • digital technology and devices to increase clinician productivity, improve disease detection and reduce hospital admissions/re-admissions
  • data-driven triggers to manage patient relationships proactively, by automating targeted communications to patients in order to ensure regular engagement with care teams and doctors.
  • works closely with the machine learning functionality and advanced predictive analytics software models to predict risk at an aggregate population or at a discrete patient level

The conclusion

We believe that the adoption of a PHM approach is a ‘must do’ if the Global population wants to enjoy equitable and sustainable healthcare. This is not simply about integration, as it requires a fundamental shift in focus from the individual-level curative approach to one that encourages doctors, hospitals and other healthcare providers to form networks or joint ventures, to coordinate patient care and share financial and non-financial risks and benefits. Our PHM is a fundamentally different economic model of healthcare, based on actuarial analyses and aligning incentives to drive clinical integration and create value.

Our focus is changing behaviors and improving health and wellbeing.