Population Health Management

Below are SAE's downloadable resources that we have developed to serve as guides for providers interested in implementing telehealth services:

SAE 2016 Telehealth Takeaways

SAE Preliminary Telehealth Readiness and Assessment Tool

SAE & Associates recognizes that an important goal of population health management is to foster an understanding of the mechanisms by which internal and external factors interact throughout the course of the lifespan to determine health outcomes. While "health" has historically been viewed as residing within the individual, influences from the social-cultural environment help to shape how people think and feel about their health, and subsequently effect personal health behaviors and practices, individual motivation, coping skills, biological functioning, interpersonal and social development, and health services. SAE is committed to helping agencies address the tremendous burden imposed by health disparities at various individual, social, and economic levels through the delivery of population health management services.

Population health management is essential to a provider's ability to effectively identify high-risk patients and deliver a strong continuum of care.


SAE believes the proper application of the principles of population health management can help providers achieve the following:

  • Improve patient care outcomes;
  • Yield cost effective interventions;
  • Improve patient satisfaction with services, and
  • Take into account cultural values, norms and beliefs of various populations of focus to improve treatment access, engagement, and adherence.

Effective population health management improves the provider’s ability to identify the needs of high-risk patients and to implement interventions that meet their needs throughout the population of focus’s continuum of care.

It has been SAE’s experience that the keys to successful population health management are:

  1. Implementation of evidence-based and promising practices (that are locally generated and relevant to the population of focus);
  2. Development of specific treatment networks with the capacity to meet the needs of the targeted population of focus;
  3. Identification of specific and effective agency-role definition within the designated treatment network;
  4. Care coordination that focuses on the needs of complex care patients;
  5. Community based strategies and programs that avoid costly, repetitive, and unnecessary treatment;
  6. Strategies that move and maintain the locus of care to the patient’s community of origin;
  7. Understanding the unique health care beliefs and cultural values of the population of focus;
  8. Data collection and analysis based on intended process and projected outcome deliverables; and
  9. Linking performance based measures and outcomes to value-based reimbursement

From our perspective, data integration is essential for effective population health management, as it measures goals and outcomes for both individual and systems providers. Data integration helps providers to report on clinical quality indicators; to develop rate negotiation strategies based on performance; and to ensure access to, and collaboration across multi sites. It is also a tool to measure agency role definition within a comprehensive treatment network of providers. In this fast changing and complex behavioral health environment, the framework for data and information exchange must be utilized as a tool to advance administrative, clinical, and fiscal functioning inherent in, and supportive of population health management.

SAE’s team of experts also understands the unique challenges of population health management, to wit:

  • A lack of seamless integration of data;
  • The presence of barriers to integration of behavioral health and primary care;
  • The need to use culturally relevant, evidence-based or promising practices;
  • Integrating behavioral health care with social determinants of health and health outcomes in general;
  • Identifying and mapping data elements that yield standard clinical value sets and set the stage for appropriate systemic course corrections

SAE’s team of experienced population health management experts provides system solution tools and step-by-step guidance to address the issues noted above, and to identify and operationalize the administrative, clinical and fiscal strategies needed for successful behavioral health population health management.

For more information, feel free to call us at (212)-684-4480 to speak with a Population Health Management team member.

Some of our key Population Health Management team members: