Based on your evidence-based proposal, write procedures or methods for a population health management program to be conducted in an applied setting (e.g., primary care, hospital, emergency department, managed care company, employee wellness program). The methods should be based on the population and intervention that you used in your Assignment 1 PHM Proposal.

TIP:  This is not a formal research study, it is an applied population health management program designed for a clinical setting. You do not need to use a randomized control design, control groups, or consent to participate. This is a proposal for a healthcare executive leadership group to evaluate, not for a research journal publication. This may be a project you can develop and implement within your internship, current or future work setting.

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Setting. A description of the setting in which this aspect of care will be addressed. Settings may include, for example: PCP office, integrated health care clinic, general medical hospital, managed care company, etc.  The setting may be a traditional mental health setting provided that it is based on the bidirectional or reverse integration model that includes a medical/health/lifestyle behavior component. Both conditions must be addressed in the setting you choose. You cannot do a traditional mental health program in a mental health setting.

Population Identification (Predictive Modeling). How will the patient population be identified? Use more than one approach (e.g., physician referral, screening, automatic referral based on EHR diagnosis, claims, etc.). Often a 2-step process is used, first identifying the medical diagnosis in the EHR, then screening for behavioral health or lifestyle behaviors. You must plan to have at least 100 patients in your program. You must describe how health technologies will be incorporated into your approach, such as measures integrated with the Electronic Medical Record (EMR), online or app-based screening tools and automated scoring, use of patient portal for communication and engagement).

Patient Engagement. How will you outreach the individuals to enroll and get them to participate in your program? Will you educate the office staff so that they think to refer to you?  Will you use telephone, email, letter of invitation, meeting during routine clinic visit, hallway hand-off, clinical rounds with the PCP, etc.? Identify a minimum of 4 outreach and engagement strategies supported by the literature. Include in-text citations and references. Describe the benefit and 1 barrier for each strategy named.

Participation. Define 1) how many patients will be identifed to participate in the study, 2) how many will actually enroll, and 3) how many will complete the intervention. A common approach to how many will be identified is to project the total number of patients in the clinic multiplied by the expected prevalence in the population. For example, if you have a primary care clinic with a total panel of 1,000 patients, and your conditions are type 2 diabetes and depression, look at the research for the prevalence of those 2 conditions in primary care, and multiply that times the panel size. If the prevalence for type 2 diabetes is 10%, then .10 x 1,000 = 100 patients, and if the prevalence of depression in 5%, then .05 x 1,000 = 50 patients that you will target, for a total of 150. To determine how many patietns will enroll in the program, note that many patients that you target for enrollment will not enroll – some will not be able to be contacted, some will decline, and some wil agree but then not show up when the program starts. To determine how many patients will complete the program, look at the drop-out rates from comparable research, and use the closest approximation for your study. Here is a sample summary for the example of a panel with 1,000 patients;100 type 2 diabetes and 50 depression:


Identified Patients

Enrolled Patients Complete Intervention Patients
150 100 80
100% 66% 53%

*Note that this table is an example, and that the projections you make for identification, enrollment and completion should be based on research based on the conditions in your proposal.

This is important because you can only use the patients who completed the program in determining clinical and cost outcomes.

Measures and stratification. What measures, specific to each diagnosis or condition, will you use to assess the patient at baseline and follow-up?  include operational definitions and for screening measures the psychometric properties (validity and reliability).  If using biometrics such as blood pressure (BP) for hypertension (HTN) or body mass index (BMI) you must cite a credible source for your thresholds such as the NIH or CDC.

Risk stratification is based on using cut-off scores from your measures to classify patients into categories that range from low to high problem severity and risk. These cut-off scores may be based upon patient self-report measures, such as the PHQ-9 for depression, biometrics, such as HbA1c percentages for diabetes, or utilization, such as number of emergency department (ED) visits. You must use at least two different types of risk stratification (see table below). Use existing published guidelines for level of severity for each measure. Stratify the population into different levels of care, based on risk or severity, so that you can tailor your interventions based on the needs of each patient (stepped care).  Do not exclude groups of patients. For example, if your topic is depression and diabetes, you can stratify based on PHQ-9 scores for depression, HbA1c percentage for diabetes, and BMI for overweight/obesity. Here is an example of stratification for type 2 diabetes and depression population:

Diabetes HbA1c Depression PHQ-9 BMI Level of risk or severity)
<5.7 5-9 18.5 – <25 Low
5.7% – 6.4% 10-14 25 – <30 Moderate
>6.5% 15-19 > 30 High


Design your interventions based on a stepped-care approach to address the level of severity for each of your risk stratification levels for each condition. Remember that your intervention must address both the medical and behavioral conditions. In the example above, you need to design interventions to improve nutrition, increase physical activity, and decrease depression. Patients with low risk may receive educational materials (brochures, web url, smartphone ap) to learn about diabetes, depression, and overweight/obesity and health risks, and how to address these problems. Patients at moderate risk may enroll in a nutrition/exercise class and a mindfulness for depression class. Patients at high risk may enroll in a collaborative care case management program that combines individual in-person sessions and follow-up telephonic meetings, antidepressant medication, plus the group interventions. Be sure to have a system where no one falls through the cracks.  If you have patients with severe risk for depression, but low risk for diabetes or obesity, you will need to mix and match the interventions to tailor the resource intensity of the intervention to the patient need. This section may be described in a table:

Condition and stratification Interventions (e.g., education, 5A’s, motivational interviewing, CBT, mindfulness, nutrition, physical activity) Modalities (e.g., brochure, web, app, in-person, telehealth, phone, text)
Diabetes Low Risk    
Diabetes moderate risk    
Diabetes high risk    
Depression low risk    
Depression moderate risk    
Depression high risk    

Duration. Define the duration of your intervention. For moderate to severe condition, a 6 to 12-month intervention period is common (e.g., the Diabetes Prevention Program is 12 months in duration). Describe the staffing for your intervention. The simplest approach is to add a Behavioral Health Consultant (BHC) such as a psychologist or social worker. Decide how many BHC FTE’s you will need based on the size of patient population that you target for the intervention. Include the time frame for the intervention from enrollment to completion of the intervention. This information will be essential for your return on investment analysis.

Expected Clinical Outcomes: Describe the general expected outcomes of your program in terms of change in measures pre- and post-intervention. Make sure to choose at least one metric from the behavioral and one from the medical condition. Choose the expected level of improvement based on the findings from your literature review. For example, the results of the diabetes prevention program research find patients achieve and maintain a weight loss of about 5% at the completion of the intervention. Note that your goals must be clear, concise, objective and measurable. Please select at least one outcome selected from national accreditation metrics (e.g., UDS, HEDIS, NQF, MACRA, STARS, etc. Use the acronym SMART to define your goals: (S=specific, M=measurable, A=achievable, R=realistic/relevant, T=time based)

Here are some examples:

There will be a 25% reduction in PHQ-9 scores for patients that complete the 12-month intervention compared to a 12-month pre-treatment baseline.
There will be a 6% reduction in BMI for patients that complete the 12-month intervention compared to a 12-month pre-treatment baseline.
There will be a 50% reduction in ED visits in the patients participating in12-month intervention compared to a 12-month pre-treatment baseline.

Describe the strengths, weaknesses, opportunities and threats to the success of your proposal. You may use a formal SWOT or PESTLE analysis.


The PHM Intervention paper should be a minimum of 5 and maximum of 8 pages (not a reference list, if needed), double-spaced, 12-point font, and formatted using APA 7th edition style. Submit the assignment as a Word doc, not a PDF.

 (25 Points)


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