Population Management

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Population Health Management & Registries
Identifying the patient population is the backbone of, and essential to, an effective population-based care delivery system. Without identification of the patients included in the population, changes cannot be effectively achieved. It is for this reason that physicians and their care teams participating in the Program are expected to utilize registry functionality to systematically maintain patient demographic and clinically relevant information based on evidence-based guidelines.  
To identify patients within the population of focus, you need to be able to access data that pertains to your patients. The tools used to collect and access information about a specific group of patients is often referred to as a registry. Simply stated, a registry is a mechanism for keeping all pertinent information about a specific group of patients at your fingertips. The information can be used to schedule visits, labs, educational sessions, as well as generate reminders and guidance of the care of patients (both in groups and individually).  
Your Patient-Centered Care Team will work closely with you to determine the mechanism and workflow for you to implement registry functionality, manage your patient population and their care needs. This process will include review of your current health information technology systems, if applicable.  
Resources:  
A starter list to use to help your practice initiate building a chronic disease registry focusing on one of five different chronic diseases including diabetes, heart disease, congestive heart failure, asthma or chronic obstructive pulmonary disease.  
A compilation of Excel registries and evidence based guidelines supporting our "Core 5" chronic disease focus areas. To be used in starting population health management implementation.  
 
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