Understanding Population Health

PHM - Defined

DEFINITION: A population health management program strives to address health needs at all points along the continuum of health and well-being through participation of, engagement with and targeted interventions for the population.

GOAL: Maintain or improve the physical and psychosocial well-being of individuals through cost-effective and tailored health solutions.

Population Health Conceptual Framework


PHM – Conceptualized

The Population Health Conceptual Framework identifies the general components and stakeholders of population health. It first depicts the identification, assessment and stratification of program participations. The core of the model includes the continuum of care, as well as patient-centered interventions. The patient (consumer) is central in the model, and is surrounded by various overlapping sources of influence on the management of his or her health. This can include, but is not limited to, organizational interventions, tailored interventions and family and community resources. Operational measures are represented under program outcomes. Finally, the cycle of program improvement based on process learnings and outcomes is prominently depicted by the large curved green arrows.

Why PHM?

A multi-faceted approach to health and well-being


  • Begins with understanding of person’s current health through assessment


  • Includes interventions for everyone in a given population, low risk to high risk


  • Broad range of approaches and activities tailored to improve the health and well-being of an individual
  • Variety of interventions can include disease-specific, workplace environment, and community resources


  • Measures impact across the range of interventions and risk continuum
  • Integral component to determine improvement in the health of a population whether focused on individuals with low risk and the goal of keeping it low, those at risk of future disease to reduce risk, those with clinical risk factors to manage them, or individuals with disease to achieve better morbidity outcomes