Manage Populations Without Analytics Platforms
Track chronic disease panels, close preventive care gaps, and document care coordination without $100K+ analytics systems. Built for small practices managing quality measures and ACOs tracking population health goals.
January 2026: TEAM Model Compliance Deadline
741 hospitals face $3-5M annual penalties for 30-day readmissions
The CMS TEAM Model (Transforming Episode Accountability Model) holds hospitals accountable for patient outcomes 30 days post-discharge. Are you ready?
The $3-5M TEAM Model Risk
30-day post-discharge accountability requires comprehensive documentation and care coordination
❌ The Compliance Challenge
- • 30-day readmission tracking across all discharge locations
- • SDOH documentation (Social Determinants of Health) required
- • Care coordination gaps between hospital and post-acute settings
- • No "line of sight" on patients after discharge
- • Manual follow-up processes miss high-risk patients
$3-5M Annual Penalty Risk
For hospitals failing to meet 30-day readmission targets
✓ OrbDoc TEAM Model Solution
- ✓ Automated 30-day accountability tracking from discharge
- ✓ SDOH capture and documentation during every encounter
- ✓ Care coordination workflows across hospital, SNF, home health
- ✓ Readmission risk flagging for high-risk patients
- ✓ Progressive HPI maintains context across care transitions
Compliance + Better Outcomes
Avoid penalties while improving patient care quality
Built for Small Practices That Enterprise Analytics Overlook
Small practices managing chronic disease panels (2-20 providers), ACOs tracking quality measures without analytics platforms, and FQHCs with population health goals and UDS reporting. Track panels and close gaps without enterprise system complexity or cost.
Population Health Documentation Challenges
Managing population health requires coordinated documentation across multiple providers and settings
Data Fragmentation
Patient data scattered across multiple providers and systems
Care Coordination
Managing complex patients across multiple specialties and settings
Risk Stratification
Identifying high-risk patients requiring intensive management
Outcome Tracking
Measuring population-level health improvements over time
Population-Level Impact
Panel Management Without Platforms
Track chronic disease panels (diabetes, hypertension, depression) without $100K+ analytics platform. Progressive HPI maintains longitudinal context across visits.
Gap Closure Automation
Identify preventive care gaps and HEDIS measures automatically. AWV optimization and care coordination documentation built in.
Care Team Coordination
Document care team communication, specialist coordination, and social services referrals. TEAM Model compliance for 30-day readmission tracking.
SDOH and Health Equity
Capture social determinants of health data in every visit. Automated forms for screening and community resource referrals.
Population Health Features
Panel Management Without Platforms
Track diabetes, hypertension, depression panels without $100K+ analytics platform
Gap Closure Automation
Preventive care gaps, HEDIS measures identified automatically
Progressive HPI for Chronic Conditions
Longitudinal tracking of chronic conditions across visits
Social Determinants Tracking
Capture and analyze social determinants of health data
Care Coordination Documentation
Document care team communication, specialist coordination, social services referrals
Readmission Prevention Tracking
Track 30-day readmissions and post-discharge accountability
Six Population Health Focus Areas
Chronic Disease Management
Diabetes, hypertension, heart disease, COPD
Key Metrics Tracked:
- HbA1c control rates
- Blood pressure management
- Medication adherence
- Hospital readmissions
Preventive Care Gaps
Cancer screening, immunizations, wellness visits
Key Metrics Tracked:
- Screening completion rates
- Vaccination coverage
- Annual wellness visits
- Early detection rates
Care Coordination
Care team communication, specialist coordination, transitions
Key Metrics Tracked:
- Care plan adherence
- Post-discharge follow-up
- Specialist communication
- Social services referrals
SDOH Screening
Social determinants of health identification and intervention
Key Metrics Tracked:
- SDOH screening rates
- Food insecurity identification
- Housing instability tracking
- Community resource referrals
Readmission Prevention
30-day post-discharge tracking and care transitions
Key Metrics Tracked:
- 30-day readmission rates
- Post-discharge follow-up completion
- Care transition communication
- High-risk patient identification
Health Equity Initiatives
Disparity reduction and equitable care delivery
Key Metrics Tracked:
- Health disparity metrics by demographics
- Language access compliance
- Care quality equity measures
- Culturally appropriate care documentation
Population Health Workflows
Population Assessment
- 1 Aggregate data from multiple sources
- 2 Identify population health trends
- 3 Stratify patients by risk level
- 4 Prioritize intervention opportunities
- 5 Develop targeted care programs
Care Coordination
- 1 Assign care coordinators to high-risk patients
- 2 Share care plans across providers
- 3 Schedule coordinated appointments
- 4 Track care plan adherence
- 5 Measure intervention outcomes
Quality Improvement
- 1 Identify quality measure gaps
- 2 Implement targeted interventions
- 3 Monitor performance metrics
- 4 Adjust strategies based on results
- 5 Report outcomes to stakeholders
Comprehensive Data Integration
Electronic Health Records (EHRs)
Health Information Exchanges (HIEs)
Claims Data Systems
Pharmacy Management Systems
Laboratory Information Systems
Social Services Platforms
Patient Engagement Tools
Public Health Registries
Comprehensive Outcome Measurement
Clinical Outcomes
- Disease-specific quality measures
- Hospital readmission rates
- Emergency department utilization
- Medication adherence rates
- Preventive care completion
Economic Outcomes
- Total cost of care per member
- Avoidable hospitalizations
- Healthcare utilization patterns
- Return on investment
- Cost per quality-adjusted life year
Patient Experience
- Patient satisfaction scores
- Care coordination ratings
- Access to care measures
- Patient engagement levels
- Health literacy improvements
Success Patterns from Population Health Practices
Primary Care Managing Chronic Disease Panels
Practices with 5-10 providers managing diabetes, hypertension, and depression panels report:
- 40-60% improvement in chronic disease measure completion
- Track 200-500 patient panels without analytics platform
- $25K-$40K quality bonus payments captured annually
ACOs Tracking Quality Measures
ACOs managing 10,000-50,000 patients without enterprise analytics platforms report:
- 65% improvement in care gap closure rates
- Automated HEDIS measure identification and tracking
- $100K-$300K avoided penalties and quality bonuses
FQHCs with UDS Reporting
Federally Qualified Health Centers managing population health goals report:
- 90% less administrative burden on UDS reporting
- SDOH screening integrated into every visit workflow
- $50K-$150K in care management fees captured
Revenue Opportunity for Population Health Management
Quality Bonus Payments
HEDIS measures, MIPS reporting for 5-10 provider practice
Gap Closure Revenue
Preventive care gaps, cancer screenings, immunizations completed
Care Management Fees
CCM, TCM, RPM for chronic disease panels (100-200 patients)
Avoided Penalties
Readmission penalties, quality measure failures prevented
Total Annual Opportunity: $203K-$540K
For practices managing 500-2,000 patient chronic disease panels
ACO Managing 50,000 Patients
An ACO reduced total cost of care by 18% in year one by tracking high-risk patients, coordinating care across providers, and closing preventive care gaps without enterprise analytics platform.
Value-Based Care Strategist Quote:
"Our strategy is to provide the right level of care at the right time and right place to counteract the various high-utilization areas and reduce the cost of care."
Reduction in Preventable Admissions
Through better care coordination and risk identification
Improvement in Care Gap Closure
Automated tracking of preventive care opportunities
Annual Savings Achieved
Through reduced utilization and better outcomes
Quality Officer Perspective: "By reducing preventable harm such as healthcare acquired infections we can shorten length of stay, reduce expense, and most importantly improve patient outcomes."
Population Health Implementation
Data Integration Setup
Connect all data sources across your network for comprehensive population health visibility.
Care Team Training
Train providers, nurses, and care coordinators on population health documentation workflows.
Analytics Configuration
Set up dashboards and reporting for your specific population health goals and metrics.
Outcome Tracking
Establish baseline metrics and ongoing monitoring for continuous improvement.
Ready to Transform Population Health Management?
Join health systems already improving population outcomes with OrbDoc
Specialized support for population health initiatives and value-based care programs