Population Health Guide for Primary Care Models


This Guide is for any health care entity working towards a patient-centered population health model of care. It can also be useful for individual primary care and multispecialty practices that are transforming into a model of care that is whole-patient, whole-population focused. The goal of this Guide is to offer education and guidance on the development and measurement of population health strategies embedded into the framework of a primary care-centered models. This Guide focuses on the overall value of population health strategies for primary care and how these strategies could be both implemented and measured based on the level of sophistication of the model. This Guide is intended as a resource for primary care-centered models regardless of where they are in the transformation process and offers suggestions and insight into specific tactics that can be utilized by any practice at both the clinician level as well as the organization level. 


  • Foreword
  • Acknowledgments
  • Population Health Overview
    • Best Practices Framework
  • Areas of Impact
    • Impacts Model
    • The Value Proposition
    • Drivers of Change and Patient Engagement
    • Care Coordination
    • Measuring Savings
  • Appendix: Special Topics
    • Medicaid and Underserved Populations
    • Oncology
  • Reference A – Health Information Technology Framework.
  • Reference B – Population Health Management Program Evaluation Methodological Considerations
  • Reference C – Evaluation Study Design Considerations 
  • Reference D – Methods to Define Outliers
  • Reference E – Evaluation Considerations for Small Populations
  • Reference F – Utilization Measures
  • Reference G – Self Management Measures
  • Reference H – Medication Adherence Measures
  • Reference I – Productivity Measure
  • Reference J – Selection Criteria Considerations
  • Reference K – Additional Resources
  • References
Contact Person/Organization: 

Care Continuum Alliance

Type of Tool:

Publication Date: 

Primary Care + Public Health

How Public Health and Primary Care Partnerships Will Improve Population Health