What is Population Health Management?

Look up the phrase "population health management," and you'll find several definitions floating around the Web. At Duke, we define population health management to include all data-informed efforts to improve the health outcomes and health services utilization of an assigned patient panel.  

Examples include:

  • proactive outreach to patients who are not obtaining recommended preventive care
  • delivery of care management services to patients who have uncontrolled chronic disease
  • interventions that improve patient engagement and provider access outside of the traditional office-based encounter (e.g., telehealth)
  • participation in accountable care organizations, narrow networks, or other networks where providers are accountable for the quality and cost of an assigned population
  • risk stratification to aid in the delivery of the right care to the right patient at the right time


Role of the Population Health Management Office

Established in 2016, The Duke Population Health Management Office (PHMO) centralizes population health delivery capabilities that were previously housed in Duke University School of Medicine, Duke Private Diagnostic Clinic, and Duke University Health System. Click here to learn about our history.

Our transdisciplinary team includes health administrators, IT professionals, providers, and over 100 care management professionals. Our goal is to facilitate higher-quality care, which results in a greater return on healthcare dollars. We achieve our impact in four ways:

  1. Delivering care management services to eligible patients
  2. Maintaining provider networks that promote high-quality care and financial accountability
  3. Supporting in-network providers with performance improvement services
  4. Participating in national and local initiatives that promote high-quality care and wiser stewardship of healthcare resources