Population Health Transformation

Improving population health is a must-do strategy in transforming health care delivery. Yale New Haven Health System, based in New Haven, Conn., has progressed quickly to improve population health management, developing data-driven interventions. The health system conducts a community health needs assessment and then uses the data to develop targeted community health programs. This assessment supported the growth of one program, Project Access, which connects uninsured community members to local health services and health resources. Another YNHHS program provides onsite care management for the health system's own employees living with chronic disease. This early-intervention initiative provides care coordination, navigation, coaching and goal setting to employees and their adult dependents. Within one year, this employee health program improved compliance with evidence-based care by 10 percent, brought risk-adjusted, per-member per-month spending in line with the general employee population and resulted in zero readmissions and avoidable admissions. The program also had 95 percent or higher participant satisfaction ratings. Yale New Haven Health System includes Yale-New Haven Hospital, Bridgeport Hospital, Greenwich Hospital, and Northeast Medical Group, a physician foundation.

For more information, contact Amanda Skinner, executive director, clinical integration and population health, at amanda.skinner@ynhh.org. The Hospitals in Pursuit of Excellence guide “The Second Curve of Population Health,” available for free, provides more case examples, metrics and information for hospitals building an infrastructure to support population health.