A 4-Step Process to Population Health Outcomes

AHP has a proven four-step process for bringing your population health management model of care from vision to action.


  1. Community behavioral health and social services needs assessment—Conducting research on the unique behavioral health and social service needs, gaps, and resources within your community
  2. Community stakeholder engagementEngaging with the community, promoting and enhancing relationships with stakeholders, and laying a solid foundation for community partnerships
  3. Population health improvement strategic planning—Facilitating the process of developing goals, setting objectives, establishing priorities, and identifying targets and measures for performance
  4. Population health management system of care implementation—Operationalizing business functions relating to technology, clinical models, financial realities, quality measures, and more

Read More: Overview of AHP’s Community-Based Population Health Management

Operationalization—6 Essential Functions

After the assessment leading to a strategic plan for your organization, implementation is essential in these six functional areas. AHP serves as your accountable care mechanic, helping you at the crossroads of primary health, behavioral health, and social services systems to streamline operations in:

  1. Clinical and service models—Analyzing and evaluating your existing clinical and service models to help you develop a set of services that provide comprehensive care to your clients

  2. Teaming and co-location—Helping your organization and partners plan and execute a bidirectional, multidisciplinary model of co-located care to improve care coordination between providers

  3. Promotion and engagement—Promoting and increasing patient and caregiver engagement and self-management to improve compliance and outcomes

  4. Technology and information management—Implementing health information technology that provides access and insight to quality and outcome measures across all systems of care

  5. Financial models—Establishing alternative payment methods, such as value-based reimbursement and bundled payments, that are inclusive of behavioral health and social service components

  6. Outcomes and quality measures—Setting metrics for measuring quality and outcomes supported by credentialing and workforce development

Knowing your organization’s strengths helps us focus on the gaps and create an overall plan for implementation. Contact us today to get started.

Your Accountable Care Mechanics

Work with AHP experts who excel at the hard, practical, and hands-on work of operationalization. Think of us as your implementation mechanics, applying oil, aligning parts, and streamlining operations for a smooth and continuous delivery of care. Together, we improve the population health of your community through efficient care coordination and integrated processes across diverse systems.