Population Health Management

Population Health Management is about knowing who's in your population, who needs help now and how the population is doing over time. Payer rosters and claims often arrive with outdated contact details and little clinical context. Zus adds each patient's outside records, normalizes and deduplicates them, and makes them available as relational tables, so value-based care teams and analysts can segment patients, find rising risk and track utilization.

The examples below show three ways teams use Zus data for population health.

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Learn more in the clinical guide

For how care teams use the ZAP to engage newly attributed patients, see Population Health Management in the clinical guide.

Before you start

• Your population enrolled in a subscription, so each record stays current through Intelligent Refresh and pushed ADT and lab data
• Access to the FHIR Relational Data Marts. See Data Mart Access Options.
• Understanding Zus data, especially how the UPID ties together every record for the same person, and how to map it to your own patient IDs

Reach newly attributed patients

Goal: contact new patients quickly, with current contact details and some context for the conversation.

1. Run the most recent phone number and most recent email queries. They return contact details from outside sources that differ from what you already have, and filter out placeholder emails.
2. Before calling, open the patient's ZAP. A recent hospitalization, a new specialist diagnosis or a refill that's due gives the outreach a reason and a starting point.
3. Prioritize by need. Patients with a recent hospital visit or complex conditions may need more intensive support than stable patients.

Result: outreach that starts with current contact details and what's going on with the patient.

Find rising-risk patients

Goal: build a cohort of patients who need attention now.

1. Start with patients who had a recent ED visit or inpatient admission, using the Transition of Care Lens query in Identifying high risk patients. It includes where and when the visit happened, diagnoses and discharge disposition.
2. Narrow by condition or medication with the same page's queries. They use the Condition and Medication Lenses, which normalize records to SNOMED CT and RxNorm where possible, so one code list catches records from every source.
3. Hand the cohort to care management, or feed it into your own risk model alongside claims.

Result: a cohort built from recent clinical events, not just last quarter's claims.

Track ED and inpatient use over time

Goal: measure utilization across your population and see whether it's moving.

1. Run the ED visits per 1,000 and inpatient admissions per 1,000 queries in Evaluating population health. They count hospitalizations from the Lens Transition of Care table, where related encounters within 36 hours are grouped into one stay.
2. Run them on a regular schedule and split by the segments you care about, such as region, age group or care team. Analyzing patient demographics has queries for geography and age.
3. Use the trend to target programs, and pair it with the rising-risk cohort above to act on individual patients.

Result: a utilization baseline you can report on, built from hospital events as they happen.

In the clinical guide

• Population Health Management: using the ZAP and data marts to reach newly attributed patients
• Quality Gap Closure

Related pages

• Query Library
• Understanding Zus data
• Quality Gap Closure
• Transitions of Care