Overview
Population Health gives care managers and clinicians proactive tools for managing their patient panel: identifying open care gaps, reviewing risk stratification, monitoring program-level outcomes, and tracking quality measure performance for AHCCCS VBP, NCQA HEDIS, and CMS MA STARS reporting.Navigation
All Population Health pages live under Clinical → Population Health.1. Care Gap Work List
The Work List shows all open care gaps assigned to your panel, sorted by severity (overdue first), then due date. Use this view to plan your outreach for the day.Filtering
- Gap type — assessment overdue, follow-up not scheduled, screening due, etc.
- Severity — overdue, due-soon, future.
- Patient — quick filter by chart name.
Closing a gap
- Click a gap row to open the patient chart in a side panel.
- Complete the required clinical action (assessment, follow-up scheduling, screening, etc.).
- The gap auto-closes when the underlying clinical event is recorded (e.g. assessment finalized, follow-up appointment booked).
- To override a gap manually (clinician judgment), select Close with reason and pick a closure reason. Manual closures are audit-logged.
2. Clinician Panel
My Panel lists every patient currently assigned to you, with their
risk tier (low / medium / high / critical) and open gap count. Click a
row to drill into the patient chart.
Risk tiers are computed nightly by the risk-stratification job from up
to four components (CL-07 safety, CL-10 outcome, CL-22 metabolic,
CL-21 MOUD). For patients without 42 CFR Part 2 consent, MOUD is
excluded and weight is redistributed across the remaining components.
3. Supervisor Panels
Supervisors see all clinicians in their team plus aggregate panel metrics: average risk score, open gaps per panel, gap closure rate, and outcome trends. Use this to balance caseloads and target coaching.4. Population Dashboard
Aggregate, organization-level dashboards covering:- Risk tier distribution
- Care gap summary by type
- Outcome trends (PHQ-9, GAD-7, etc.)
- Disaggregation by site, program, payer, age band, primary diagnosis
<5 (HIPAA Safe Harbor de-identification).
5. Quality Measures
The Quality Measures page shows HEDIS and CMS MA STARS measure period results for the selected reporting year:- AMM — Antidepressant Medication Management (acute / continuation)
- IET — Initiation & Engagement of SUD Treatment
- FUH / FUM — Follow-up After Hospitalization / ED Visit (sourced from CL-29-EN-65)
VBP Export
Users withcl.quality-measures.export may export the VBP CSV for
AHCCCS reporting. The CSV contains aggregate metrics only — never
patient identifiers — and applies small-cell suppression.
Permissions Summary
Need help?
- Admin guide: Population Health Admin Guide
- Cross-core integrations: Population Health Integration
- Email: admin@example.org