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(CHI) Community Health Institute and Expo

CMA1 - Population Health Improvement Projects: Lessons Learned From the Field

Aug 28, 2017 8:00am ‐ Aug 28, 2017 9:30am


Effective population health management is essential for health centers to flourish in a value-based environment by applying a comprehensive, community-centered approach to improving the health of populations and patients they serve. The aims are to: (1) support CHCs in identifying and engaging an at-risk target population and applying interventions that upgrade processes of care, strengthen local partnerships, and address social determinants; (2) expand population health management capacity to additional patient or community target populations and additional social determinants of health; (3) enhance the potential for sustainability of the interventions, partnerships, and population health capacity; and (4) develop and implement a learning community to share information among grantees and to promote and expand collaboration through information sharing with partners and other audiences. This session will address the strategies, data needs, early process, and outcome improvements in developing and tracking effective population health management in health centers. The audience will hear the lessons learned from RCHN Community Health Foundation and how they utilized their learning community specifically as a performance improvement strategy, with a diverse group of CHCs, that led to specific projects and interventions to produce very favorable outcomes. This session will also provide the payer's perspective on how demonstrated, effective population health management supports the value equation in both outcomes and payments.

  • - Identify the strategies, data needs, early process and outcome improvements needed to develop and track effective population health management in health centers.
  • - Understand the key lessons learned when using a learning community specifically as a performance improvement strategy.
  • - Examine how effective population health management can support and demonstrate the outcomes and payments of the value equation from the payer perspective.


  • Jessica M. Fraser, Director, Care Management, Hudson Headwaters Health Network
  • Feygele Jacobs, DrPH, President & CEO, RCHN Community Health Foundation
  • Ms. Jennifer Nolty, Director, PCA and Network Relations, NACHC
  • Rachelle Ocampo, EdM, Associate Director, Health Education, Charles B. Wang Community Health Center
  • Jessica Sanchez, RN, FNP, MSN, Vice President, Quality and Operations, Colorado Community Health Network
  • David Stevens, MD, FAAFM, Research Professor, Milken Institute of Public Health, The George Washington University

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