Population Health Management & Integrated Care Pathways Training Course

Course Overview

Learning Objectives

• Explain the principles of population health management and how they differ from episode-based service management.
• Define target populations and segment them by health status, need, service utilization, and social circumstances.
• Apply risk stratification methods to identify high-risk and rising-risk groups and set program priorities.
• Design disease and population registries with clear data definitions, ownership, quality controls, and update routines.
• Evaluate the data sources, data-sharing arrangements, and privacy safeguards required for population-level analytics.
• Design integrated care pathways that connect primary care, hospital services, home care, and community resources.
• Establish care coordination, referral, transition, and handover arrangements that reduce gaps between care settings.
• Develop case management and long-term condition management programs for priority population segments.
• Incorporate social determinants of health, community partnerships, and patient engagement into population programs.
• Assess payment, contracting, and financial incentive models that support integrated, value-based care.
• Design governance structures, performance indicators, and evaluation methods for population health programs.
• Develop an implementation roadmap that addresses stakeholder resistance, workforce roles, and change management.

Who Should Attend

Learning Outcomes

• Explain the purpose, components, and operating model of population health management.
• Define an accountable population and assess its health needs and service gaps.
• Segment populations and apply risk stratification to set evidence-based program priorities.
• Specify disease and population registries with sound data governance and quality controls.
• Design integrated care pathways linking primary, hospital, home, and community care.
• Establish referral, transition, and handover arrangements that close gaps between care settings.
• Develop care coordination and case management programs for high-risk population groups.
• Integrate social determinants of health and community partnerships into program design.
• Assess payment and contracting models that reward integrated, value-based care.
• Design governance structures and accountability arrangements for population health programs.
• Select indicators and evaluation methods to measure program outcomes, experience, and value.
• Prepare an implementation roadmap that manages stakeholder resistance and supports scale-up.

Course Outline