Population Health Foundations
This opening module introduces the core principles of Population Health Management (PHM) and lays the groundwork for the entire series. Participants will explore how engaging patients, aligning multidisciplinary care teams, and addressing whole-person needs can improve outcomes and advance value-based care.
Click a session below for a brief overview, or click here to view the full agenda.
Click a session below for a brief overview, or click here to view the full agenda.
Wednesday, February 18, 2026
Kick-off Session: Introduction to the Population Health Management Framework
Kick-off Session: Introduction to the Population Health Management Framework
The Population Health Management (PHM) Framework improves patient outcomes by engaging patients in their care and aligning coordinated care teams. By breaking down silos and focusing on whole-person care, PHM fosters collaboration among providers to address patient progress and barriers. This session introduces the core elements of PHM and provides a high-level overview of the framework that guides the series.
Learning Objectives:
Learning Objectives:
- Define Population Health Management and how it differs from historically provided care.
- Understand the various aspects of population health management at a high level and key elements needed for success at each stage.
Wednesday, February 25, 2026
Engage: Patient Attribution and Patient Engagement
Engage: Patient Attribution and Patient Engagement
Patient attribution and engagement are essential to value-based care success. This session defines patient attribution, explores its link to patient engagement and outcomes, and shares practical strategies health centers can use to operationalize both to achieve quality and financial goals.
Learning Objectives:
Learning Objectives:
- Define the role of patient attribution in value-based care and its implications for health center performance.
- Understand how patient engagement impacts clinical outcomes and overall care quality.
- Identify effective strategies and tools for operationalizing patient attribution and engagement in practice.
Wednesday, March 4, 2026
Assess: Clinical, Behavioral, and Social Gaps, Needs and Risks
Assess: Clinical, Behavioral, and Social Gaps, Needs and Risks
Comprehensive patient assessments are essential to identifying patient strengths, needs, and goals and creating effective, whole-person care plans. This session explores the role of social influences on health and how to move beyond siloed care by scaling care team interventions based on patient risk for efficient, high-impact resource use.
Learning Objectives:
Learning Objectives:
- Define what makes an assessment comprehensive.
- Understand ways to incorporate social determinants of health into care coordination efforts, ensuring a holistic approach to patient care that considers the broader factors influencing health and wellness.
- Identify opportunities for patient and family engagement in the assessment process recognizing their valuable insights and contributions to the development of effective care plans.
- Connect the information collected via the assessment process to a patient centered plan of care.
Wednesday, March 11, 2026
Manage: Patient-Centered Care (Health Equity and Social Drivers of Health) Assembling and leveraging the Care Team
Manage: Patient-Centered Care (Health Equity and Social Drivers of Health) Assembling and leveraging the Care Team
Effective care coordination depends on strong communication and collaboration. This session explores how to identify the right care team members and emphasizes ongoing collaboration to ensure coordinated, comprehensive care plan execution.
Learning Objectives:
Learning Objectives:
- Defining the care team and how to best identify which providers or entities should be a part of the care plan.
- Identify methods to help facilitate the exchange of critical patient information among healthcare providers to ensure that all members of the care team have access to relevant data, leading to better informed decision making.
