Population Health

The Massachusetts eHealth Collaborative (MAeHC) has a vast history of assisting organizations with developing risk stratification criteria, data analytics, and patient centered care plans.  

The MAeHC team has two PCMH Certified Content Experts (CCE) on staff and have helped over eighty-five sites transform into Medical Homes.  Every site recognized has had to implement data analytics, risk stratification for the identification of patients for care management and implement written care plans to meet the minimum requirements for recognition.  Practices submitting for recognition must determine a priority population to track and provide care management services.  The criteria for stratifying risk much include patients within the categories listed below:

  • Behavioral health conditions
  • High cost/high utilization
  • Poorly controlled or complex conditions
  • Social Determinants of Health (SDOH)
  • Referrals from outside organizations

The NCQA model of care requires organizations to not only stratify patients for risk, but also requires providers document a care plan within the EHR at all relevant annual and follow up visits for the identified patients. MAeHC assists practices with identification of the priority populations within each category.  We also work with all NCQA practices to document the items that must be addressed within the care plan, such as incorporating patient preferences and lifestyle goals, identifying treatment goals, assessing and addressing potential barriers to care, include a self-management plan and provide the plan to the patient or family in writing.  The care plan must also address medication management, requiring providers to perform medication reconciliation, document patient understanding of medications, barriers to medication adherence and the documentation of over the counter medications. 

Data analytics for all PCMH practices supported must be implemented as well.  Practices must implement processes to monitor the percentage of patients within each category for risk stratification and overall percentage of patients out of the entire populations.  They must also analyze performance against documentation of the necessary sections of the NCQA care plan.  Lastly, the organizations must implement a full system for quality data analytics around utilization, accessibility, patient experience and process and outcome measures across many areas of care (preventive care, chronic care, acute care, immunizations, etc.).

Example Project:

The MAeHC team can assist your organization with the acquisition, implementation and/or optimization of population health IT software.  Our team can also leverage and configure your current EMR system to focus on population health activities, such as preventive and chronic care outreach, identification and flagging of high-risk patient population and closed loop processes for referrals and tests. 

Our organization offers Event Notification Services (ENS) to help organizations of all types manage populations through automatic notifications of hospital and ED discharges.  Our team will help with the setup, workflows and integration with your Vendor.