Iowa Healthcare Collaborative

Population Health


Population health refers to the approach of providing evidence-based interventions to a defined group of patients with similar needs in order to improve health outcomes. Population health encompasses multiple strategies including but not limited to risk stratification, person and family engagement, prevention, chronic care management, and appropriate management of care transitions.

An important aspect of population health is the ability to identify high risk populations within a practice. This can be accomplished by gathering pertinent data from the electronic health record, a registry, or even by utilizing an Excel spreadsheet. The gathered data can then be used by the practice to define and identify the outcomes which could be improved by implementing population health strategies.

Understanding and successfully implementing population health is essential to practice transformation.

Please review the resources provided. If you are not able to find the resources you are looking for, or if your organization is enrolled in Compass PTN and needs help with implementing a population health program, please contact Lori Galioto, Population Health Specialist, at (email).


Empanelment is the act of assigning individual patients to a primary provider and care team who will be responsible for that patient.


SafetyNet Medical Home Initiative (Link)
Interactive website with a section on empanelment. 

Establishing Patient-Provider Relationships - Executive Summary (PDF)
Document created by SafetyNet Medical Home Initiative.

Establishing Patient-Provider Relationships - Implementation Guide (PDF)
Document created by SafetyNet Medical Home Initiative.

Team-Based Care

Creating an optimizing an effective care team involves strategically redistributing the work among members of a practice team. Matching the work that needs to be done to the strengths and abilities of each care team member leads to better coordinated patient care, more engagement of the team members, and improved joy in the workplace.


Primary Team Care Guide (Link)
This guide features interactive modules.

American Medical Association (AMA) STEPSforward Online Module: Implementing Team-Based Care (Link)
An interactive module that provides implementation guidance for team-based care along with resources and helpful documents.

Institute for Healthcare Improvement (IHI): Optimize the Care Team (Link)

The Agency for Healthcare Research and Quality (AHRQ) White Paper on Creating Patient-Centered Team-Based Primary Care (PDF)
This paper proposes a conceptual framework for the integration of team-based care and patient-centered care in primary care settings, and offers some practical strategies to support implementation.


AMA STEPSforward Interactive Module - Team Huddles (Link)
Downloadable tools for implementing daily team huddles. CME available upon completion. 

Healthy Huddles (Link)
The Center for Excellence in Primary Care has great resources for implementing huddles.

Health Coaching

AMA STEPSforward Interactive Module - Health Coaching (Link)
Walks through the process of implementing the health coach role. CME is available upon completion. 

Risk Stratification

Risk stratification is a process for identifying the risk category for an individual patient and also a process for identifying high risk populations. Having a consistent risk stratification process is essential for targeting population health strategies.


Identifying Important Conditions (Word Document)
This document developed by the American College of Physicians describes a risk stratification process using a billing or EMR system to identify the most frequent and most important conditions in a practice.

American Medical Association (AMA) STEPSforward Online Module: Implementing a Point-of-Care Registry
An interactive module discussing the use and implementation of a point of care registry to monitor high risk patients. CME credit is available for completing this module.

Minnesota Care Coordination Tier Assignment Tool (PDF)
The Tier Assignment Tool is an example of risk stratification through manual classification.

SafetyNet Medical Home Initiative - Empanelment (Link)
Has an example of a patient acuity rubric on their website under ‘Tools’.

The American Academy of Family Physicians (AAFP) (Link)
Risk stratification rubric free to AAFP members.

Population Health Tools


Partnering in Self-Management Support: A Toolkit for Clinicians (Link)
This toolkit developed as part of an initiative of the Institute for Healthcare Improvement (IHI) and funded by the Robert Wood Johnson Foundation can be downloaded from the IHI website. You will need to create a free account at IHI. This account will give you access to IHI tools and resources.

AMA STEPSforward Interactive Module - Patient Care and Engagement (Link)
How to initiate a population health program with downloadable tools and resources.

Billable Medicare Services


List of Assorted Resources (Link)
Regarding annual wellness visits (AWV), transitional care management (TCM), chronic care management (CCM), advance care planning and more.

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