1. Determine which populations you have total responsibility for outcomes and costs.
  2. Choose your population segment and learn about the root causes of high utilization and the assets that can be leveraged to improve outcomes.
  3. Determine which subgroups will be impacted by your enhanced care model.
  4. Secure initial and ongoing investment in improving care for your population.

1. Determine which populations you have total responsibility for outcomes and costs.

Establish a multidisciplinary leadership group with representation from key stakeholders to choose your population and lead the development of your enhanced care model.
  • The leadership group can study the data and review the considerations listed below to first choose the total population to draw from, and then to determine the population segment with complex needs and high costs and its subgroups for whom the enhanced care model will have the most impact.
  • Developing an enhanced care model typically requires the addition of resources and can take three to five or more years to demonstrate a return on investment. The leadership group, therefore, needs to think about and plan for the long-term sustainability of the proposed enhanced care model at the outset.
  • Consider the following, for which dedicated time and resources are needed:
    • Determine the strategic drivers for your organization to invest resources in redesigning care for people with complex needs and high costs.
    • Study the potential populations for whom your organization is responsible for total health care costs and other outcomes, such as health, experience of care, and quality of care delivery.
    • Consider the current and future financial incentives for serving different populations.
    • Identify the current services your organization provides and those it does not.
    • Explore existing resources in your organization and in the surrounding community.
    • Brainstorm how an enhanced care model may impact the outcomes for the populations that your organization is considering.
    • Consider not just cost alone, but other strategic priorities such as the low pay/no pay population segment, provider relief and retention, access to data, who will fund the enhanced care model, and who is interested in partnering to support the needs of the population with complex needs and high costs.
    • Understand the visions and goals of four key stakeholder groups — patients, payers, providers, and leaders of your health care delivery system (including the Chief Executive Officer, Chief Financial Officer, Chief Medical Officer, and others) — and identify how the enhanced care model for the population with complex needs and high costs aligns with those visions and goals.
Determine the population for whom your organization has responsibility for total health care costs and other health outcomes.
  • Good population management starts with determining the people for whom your organization is responsible for total health care costs and other outcomes. For example, many organizations have a strategic interest in improving health, experience of care, and health care costs (the IHI Triple Aim) for specified populations. Identify the populations for which your organization has responsibility for total costs and other health outcomes. Your organization may have multiple such populations to choose from. Read “Pursuing the Triple Aim: The First Seven Years” to learn more about IHI’s work on the Triple Aim.
  • Core to managing a whole population towards better outcomes at lower costs is understanding the different segments, or subgroups with similar needs in the population. Population segments are useful when the care delivery is distinct for different segments; if effective care delivery does not differ between segments, segmentation is not practical. Once meaningful population segments are identified, the team can learn more to determine each segment’s needs and assets. Only then can the team design services to meet those assets and needs and expand service delivery to reach full scale.
  • Populations can be segmented through a number of lenses; here are some examples:
  • Figure 2 shows the sequence of work for effectively redesigning care for a population segment. The initial step after choosing a population segment is to deeply understand their needs driving less than optimal outcomes.  Understanding needs leads to identifying the services required to effectively meet the needs. Goals for the delivery of the services and coordination of the services are identified as a care model is developed to effectively deliver the services. Understanding full scale, or all the people who will need the services in the population, from the beginning, provides a realistic view of the trajectory the program needs to reach to benefit the most people.managing-services-for-a-population
Tips and guidance for determining the population for whom your organization is responsible for total health care costs and other health outcomes:
  • Engage a core group of leaders who understand and support your organization’s enhanced care model and can dedicate staff time and resources to support this work.
  • Conduct a to find populations that align with the strategic interests of stakeholder organizations, to help secure ongoing leadership support and sustainability of your efforts.
  • Keep your organization’s vision and goals at the center of this work, and ensure that organizational leaders support the choice of your chosen population with complex needs and high costs.
“Coming from a health plan background, we think about Medicare, Medicaid and commercial populations, and knowing that each of those groups has different needs and they need different interventions. That was one of the big things for us, looking at them separately, as opposed to in one bucket.

We learned through experience that probably about 50% to 80% of the Medicare population is going to need complex case management, whereas for individuals with commercial insurance it is about 3%. We staffed according to population and the need.”Joann Sciandra, RN, BSN, CCM, Associate Vice President, Population Health, Geisinger Health Plan



“I think that choosing the population is very locally based. For example, some programs that I’ve seen, I think of San Francisco and a couple others, are really good from the standpoint of housing. At this point, 20% to 30% of our patients lack housing and they are literally on the streets or they’re in a shelter. We have been able to get a fair number of patients housed or we were with them when they became housed. Understanding the needs and what the intervention needs to be is really important in terms of choosing the target population and deciding, for example, whether or not you want to try and do addiction treatment within your walls or outside your walls, because that might also impact your selection of patients.”Jeremy Long, MD, MPH, Associate Professor, Division of General Internal Medicine with the Denver Health and Hospitals, Department of Medicine

2. Choose your population segment and learn about the root causes of high utilization and the assets that can be leveraged to improve outcomes.

Understanding the needs and assets of the individuals in your chosen population segment is core to designing effective and sustainable care systems. This is especially true for people who have complex needs and high health care costs. Review what you have learned about your population, considering clinical and utilization data, interviews with patients, and provider input: a 3-Part Data Review.

  1. Review all available data.
  2. Seek clinical input.
  3. Learn from lived experience by interviewing individuals in the likely chosen population.


As you conduct your 3-Part Data Review, look for cost drivers and consider whether these drivers can be impacted by your enhanced care model. For example, some people have expensive care that should not be taken away, while others have experienced a physical trauma or an other event with time-limited effects. It’s key for your organization to understand the characteristics of the people who are at risk for accruing high costs in the future, using this information to then design an enhanced care model that specifically addresses their needs.

Organize the information using the 3-Part Data Review worksheet, or a similar format.

As CareOregon was developing their Health Resilience Program, they did a deep dive into there root causes. Review CareOregon’s three part data review process.

Review available data to learn about utilization and begin to recognize patterns of utilization among the people included in your population.
  • Learn about the top 1%, the top 5%, and the top 2% to 10% of the population and what is driving their high utilization of health care services. Useful questions include:
    • What data do you have access to that provides insight into people who have complex needs and high health care costs?
    • What did you learn from this data (e.g., number of patients, diagnosis codes, disease burden, undocumented patients or those who rely on charity care, care delivery sites, other)?
    • What themes emerged?
    • What, if anything, surprised you? What new questions do you have?
  • Learn what information is available within electronic health information systems or data warehouses. When possible, review:
    • Claims or utilization data from the payer or your own system encounter information (including hospital, emergency department, and primary and specialty care systems). In the US, some insurance providers may be more open to sharing data and willing to pay for good outcomes for certain patients. Review this IHI resource for tips and strategies on partnering with payors.
    • Behavioral health encounter or claims data
    • Electronic health record notes from primary care visits, including problem lists, diagnosis codes, care plans, and After Visit Summaries
  • Explore other sources of data to understand additional forces that may contribute to high health care costs:
  • Look at your data through the lens of health equity, and stratify data along one or several of these indicators to learn where gaps may exist. Research shows differences in health care quality, access, and outcomes based on race, ethnicity, socioeconomic status, sexual orientation, gender identity, and other factors that may impact health equity.
    • Within your population, identify which groups of people have poorer outcomes than others.
    • Look at utilization and other patterns to help you understand if some groups are challenged in using your services.
    • Review available resources to create a plan for how you will resolve health equity issues
Interview care providers who work with your population to understand their perspective on the root causes of high utilization.
  • Useful questions include:
    • Which patient groups have complex needs and are likely to have high health care costs (e.g., frail older adults, children with three or more health conditions)?
    • What are the needs and assets of people who are not well-served by the current health care system?
    • What are the biggest challenges your organization faces in fostering good patient outcomes?
    • What individual or community assets help patients get their needs met?
  • Look for “pain points” in the health care delivery system:
    • Which patients do primary care physicians want help serving?
    • Which patients overwhelm emergency departments or have lengthy stays in inpatient care?
Interview 10 to 15 patients in your potential population segment to understand their perspectives on the root causes of high utilization.
  • Patients are often the most overlooked source of deep insight into the challenges and barriers that are the core root causes of high utilization. The goals of patient interviews include hearing the patient’s perspective; understanding what is important to them (often different from the health care team’s goals); learning the real-world challenges they face in managing their health conditions and living situations; determining their assets and resiliency; and identifying what interventions may help them.
  • The art of these interviews is to take off the “health care hat” and use deep listening skills. As you listen to people tell their story, look for the root causes of  high health care utilization and consider if what you learn suggests the need to focus on potential subgroups of your population with complex needs and high costs. For excellent examples of the kinds of information that will emerge in these interviews, visit the Camden Coalition Hotspotting Curriculum and listen to the patient stories included.
    • Use a structured tool, such as the HARMS-8 and/or Patient Activation Measure as a way to guide the conversation and gather information to understand themes.
    • Identify the team member/s who are good at gaining trust, engaging individuals in conversation and listening well. Similarly, note team members who are not suited to this task and ensure that they do not take a central role.
    • Ask Primary Care Providers or Care Managers working with individuals from the potential population to introduce the person doing the interviews.
    • Test whether phone calls to individuals are effective at engaging individuals in your setting. In-depth conversations are usually richer in person and offer the additional lenses of eye contact, facial expression, and body language.
    • Approach the interviews as a human conversation, not a research project.
Tips and guidance for identifying individuals with complex needs and high costs, and learning about the root causes of high utilization:
  • Knowing the characteristics of your chosen population is the start to understanding and selecting your population segment with complex needs and high costs.
  • There are several methods that you can use to learn about the needs and assets of your target population. Consider conducting a small series of narrative case studies or use standardized assessment instruments such as the HARMS-8 and the PAM.
  • Interview patients that are involved in your enhanced care model, as well as those that are eligible for your enhanced care model.


“Our goal is to reach the right population for our enhanced care model, so we used the inductive approach. That meant putting aside our assumptions about who we thought we were serving, and actually going out to meet people, hearing their stories and getting their input about what might work best for them. We started by screening people who came to TrueNorth, a social services agency in Newaygo County, to see if they would be willing to share their experiences managing their health. We would interview them and collect their stories as well as their feedback. The plan was that once we put their stories together, we would present them to our improvement team, who would then identify common themes. To ensure consistency in our process, we used tools we learned from the IHI Better Health Lower Costs Collaborative. The three main tools we used were the HARMS-8, the ACE, the PAM.


Our first round of interviews were an eye-opening lesson for us. We took a big swing at a big problem, and we missed. We started by using primary care as the initial entry-point for engagement with our target population. What we found was that these individuals are in more advanced stages of health crises. Strategically, we wanted to catch people before their health crisis flared up. So we took a different approach that has allowed us to get to where we are today. That approach involves interviewing individuals and seeking their feedback. As a group, we realized that we think we can walk into a room and know what the issues are. The reality is, we can’t just fix it. We’ll miss the mark. So we’re learning to slow down, take a step back, and actually involve the individuals that are going to be affected the most. It would have been nice to know this at the beginning of our work.” Shelly Johnson, RN, MPH, MBA, FACHE, Chief Operating Officer, Spectrum Health Gerber Memorial

3. Determine which subgroups will be impacted by your enhanced care model.

Your organization’s population with complex needs and high costs likely includes subgroups with different needs and assets, such as frail older adults, people experiencing homelessness, and people with multiple chronic or behavioral health conditions. Understanding the needs and assets of these subgroups is useful because it may suggest the need for tailored care approaches.

Review key themes from the 3-Part Data Review to identify potential subgroups of your population with complex needs and high costs.
  • Summarize the information from the interviews using the 3-Part Data Review worksheet or a similar format. For examples, visit Lessons from the Field.
  • In your team, discuss the themes that emerged from the patient interviews. Questions to consider:
    • What needs or challenges emerge?
    • What, if anything surprises you?
    • What strengths or assets come through?
    • Given the needs, what interventions are likely to be needed?
    • Do the needs point to a homogeneous group of individuals or different subgroups? For example, middle-age individuals with chronic conditions and a mental health issue may have different needs from elders with chronic conditions and a mental health issue; adolescents with substance abuse may have different needs than pregnant women with substance abuse.
  • Consider how well (or not) patient assets, needs, and preferences align with current care.
Tips and guidance for determining which subgroups of the population with complex needs and high costs will be most impacted by your organization’s enhanced care model:
  • Begin to consider the care implications for each subgroup within the target population. The need for distinct enhanced care models is an indicator that additional subgroups could be useful.
  • Clearly describe your rationale for choosing distinct subgroups within your chosen population segment with complex needs and high costs.
  • Is your envisioned or current enhanced care model capable of addressing the unmet needs of your target population, or can the model be adapted to meet their needs? Can health care services play a significant role in improving the health of your chosen population?
  • Determine whether your organization currently has the competencies to serve the population with complex needs and high costs, or wants to develop these competencies. Ensure that your organization is willing to dedicate resources to help develop competencies where they do not exist.
  • Consider partnering with an academic or research institution to better understand the unmet needs and the assets of your chosen population segment with complex needs and high costs.

4. Secure initial and ongoing investment in improving care for your population.

Ongoing engagement with key stakeholders, developing a shared vision, and articulating expectations for results from the enhanced care model are all essential for securing ongoing investment in your enhanced care programming. A solid understanding of the desired strategic outcomes, the needs driving high utilization, and the available assets and resources can help your organization choose your optimal population with complex needs and high costs, and then develop and grow your enhanced care model.

Use the following steps to synthesize and frame your findings in ways that enable the team to advocate for long-term funding for the enhanced care model:
  • Build a relationship with key stakeholders in the organization and in the community that assumes financial risk for this population, and work together to create a shared vision for the enhanced care model.
  • Periodically revisit your stakeholder analysis for the proposed enhanced care model. Does each key stakeholder favor the success of the model? Does the model make any key stakeholders vulnerable? Are stakeholders in support of, neutral to, or at odds with the success of the enhanced care model?
  • Clearly articulate and document the rationale for choosing the specific population with complex needs and high costs, and create an initial draft of the rationale for continuing to invest in this population segment. Tailor the messaging and discussion for different audiences, as appropriate.
    • Document how focusing on this population segment can act as a lever for reducing costs.
    • Calculate the potential cost of the intervention compared to potential avoided or saved costs.
  • Meet in person with these stakeholders and discuss how your findings and potential population segment with complex needs and high costs aligns with their view of costs, how they define success, and their motivation to achieve desired outcomes for this population. Explore other ways to partner:
    • Will they give timely access to utilization data?
    • Will they help recruit patients into the enhanced care model?
    • Will they set aside resources to provide enhanced care programming?
    • Will they deploy care managers from other areas in the organization to the enhanced care model?
“We’re now at a point where we have this great group of people aligned in different institutions who are working together. But at the start, we didn’t have that; it was just sort of a blank sheet of paper. We had to build our stakeholder group. We learned it’s important to think about who all the players are and try to anticipate the wins and losses of why those institutions may or may not have skin in the game, and if they don’t, figure out how to help them put some skin in the game.”Jeremy Long, MD, MPH, Associate Professor, Division of General Internal Medicine with the Denver Health and Hospitals, Department of Medicine
Tips and guidance for creating a path forward for securing initial and ongoing investment in programming for your population with complex needs and high costs:
  • Create a communication plan customized to key stakeholders; consider the use of language, focus of the interactions, desire for data, stories, or data and stories.
  • As new stakeholders join the work, engage with them as soon as possible to ensure there is a shared vision, alignment, and support for the enhanced care model, and to identify the need for modifications to the model if necessary.


“I learned to pay attention to the four audiences in order to sustain programs. One of the audiences is the clinicians who refer patients to the program. Another audience is the patients themselves because it turns out self-referral is by far the leading way we get patients, not because somebody else sends them to us. The third is institutionally, and the fourth is the health plan. The work never ends. You have to constantly engage these four groups. For example, every month we send a report out, including our enrollment and whatever new result we have; if we have some piece of data that we can parade out, we parade it out.”Alan Glaseroff, MD, Co-Founder, Stanford Coordinated Care