September 18, 2019

Provider Perspectives on Population Health in Primary Care

Partners Population Health Perspectives blog aims to share the opinions and ideas of our leadership team on health care topics related to population health management. For this post, we asked primary care leaders from across the Partners HealthCare system to share their personal experiences utilizing population health management programs.


At Partners HealthCare, our Population Health team designs, builds, implements and evaluates clinical care redesign efforts aimed to achieve five main goals:

  • Improve quality of care;
  • Slow down the overall growth of health care costs;
  • Enhance care coordination;
  • Engage patients in their own care; and
  • Use technology and analytics to support patient care.

But with a shortage of primary care providers looming on the horizon, and the prevalence of provider burnout rising, the Partners Population Health team is increasingly focused on understanding how these care redesign initiatives are impacting primary care practices and their indispensable primary care providers (PCPs). To dig into the day-to-day life of our PCPs, we asked providers from across the Partners HealthCare system to share their personal perspectives on population health with us. Here’s what they had to say:

Editor’s Note: Responses have been lightly edited for length and clarity


population health primary care

Dr. Sonal Mankodi, Primary Care Provider, Mass General/North Shore Center for Outpatient Care

“Over the last five years, population health programs have become more and more a part of my daily care of the patient. As my practice first began establishing our Patient-Centered Medical Home, we had some of these programs on the periphery, but now they’ve become an integrated part of our everyday work. First and foremost, they have positively impacted the patient, but they also benefit me as a provider because they give me access to many tools and resources that I can use to provide focused, skilled and specialized care for my patients.

Early in the implementation of our high-risk care management program, the “Integrated Care Management Program (iCMP),” my practice had an iCMP nurse and a social worker embedded within our practice. These two care team members have a very strong and collaborative relationship; they truly work seamlessly together. From the moment they joined the team, the iCMP nurse and social worker both established themselves as valued assets in my practice, working very closely with myself and other PCPs to help provide frequent touches to our most vulnerable and difficult to care for patients.

I have had several patients who have benefitted from the iCMP Program. In these high-risk, medically complex cases, one thing I’ve noticed is that the patients utilize the iCMP Care Manager as their focal point of access to care to our office. They find it so comforting to meet the iCMP Care Manager in the office, put a name to a face, and then have them always be available, whether it’s in the office or by phone. This dynamic has been transformative for a lot of patients because oftentimes, patients don’t feel like they have an easy point of contact into their primary care office. As a result, they might panic whenever a health problem arises and decide that going to urgent care or the emergency room is a better option. But by now having this stable contact with the iCMP Care Manager, we have prevented a lot of patients from feeling that sense of unease, and they’ve actually called the office and been able to avoid these emergency care settings. This not only prevents a lot of high costs, but also allows the patient to avoid the inconvenient care of an unnecessary emergency room visit.”

population health primary care,

Dr. Stuart Pollack, Medical Director at Brigham and Women’s Advanced Primary Care Associates, South Huntington

“One aspect of population health that I see as a truly major breakthrough is the integration of behavioral health into the primary care setting. For the first 15-20 years of my career, the medical field treated the mind and the body as separate. This presented a problem for PCPs like me because we didn’t have access to behavioral health resources. But in reality, there’s a lot of medical problems that are very difficult to treat if you don’t first deal with the underlying behavioral health problems or issues around social determinants of health. For example, if you look at a population of people with diabetes who are not in control, most of the time the problem isn’t the diabetes treatment itself. Rather, the problem is that the patient can’t manage their diabetes because they are depressed, or the patient doesn’t have a refrigerator and can’t maintain a healthy diet as a result.

But today, with the introduction of the Partners Collaborative Care Team, I now have access to a suite of behavioral health interventions within my practice, so we are much better equipped to address these issues in our patients. These resources have empowered us to keep behavioral health on our radar every day here at South Huntington, so if we find that patients are dealing with depression, anxiety, or have a psychiatric disease, we have a range of interventions readily available to help them.”

population health primary care,

Dr. Denise Mayo, Medical Director at Newton-Wellesley Physicians Primary Care

“Population health has completely changed the way I practice medicine. As a PCP, I have some really sick patients with lots of needs. Usually, it’s a combination of medical, social, and behavioral needs all rolled into one complex patient. When I first came here to Wellesley, I was pretty much on my own trying to find therapists and psychiatrists for patients, so that was a huge time consumer. If I had complex care patients, it was not unusual for me to spend time at the end of my day trying to figure out how to get them a walker, brace or whatever else they needed. Now that I have access to so many resources through the various population health programs, my workflows have significantly improved and I can really focus on the immediate medical needs of my patients.

For instance, with the high-risk care management program (iCMP), I have a Chronic Care Management Nurse as a resource right at my fingertips, which is a major benefit because it helps unload my burden and makes me more supportive to these complex patients’ needs. In my practice, I sit right outside the door of the Chronic Care Management Nurse, and there is a steady stream of doctors, medical assistants, triage nurses and other care team members walking in and out of her office all day. It is amazing to be able to witness first-hand the impact that this program and others have on the well-being of our patients every day.

At the same time, I also feel the population health programs have had tremendous benefit to myself and other clinicians. In particular, the transition to the Patient-Centered Medical Home has provided our practice not only with better workflows and improved efficiency, but has also enhanced our practice’s culture. We have low turnover, low absenteeism, and I’d say a much happier staff and physician population than other places that don’t have these programs. If one of my support team happens to be out one day, we feel the pain of their absence because we are so integrated.”

population health primary care,Dr. Alexy Arauz Boudreau, Director for Population Health Management, MassGeneral Hospital for Children; Medical Director, MGH/MGPO Medicaid Accountable Care Organization (ACO)

“One population health program that I have recently found beneficial is our Emergency Department (ED) Navigator program. For this program, case managers, social workers and ED providers formed an interdisciplinary team to help support the establishment of a non-clinical role in the emergency department. This is a truly innovative approach that has allowed us to better connect with patients and their families. By providing a layperson’s voice, the ED Navigator acts as a translator between patient and provider, making sure that the patient is understanding what’s going on, as well as addressing some of their social needs when appropriate.

One patient I had was a young mom. I hadn’t seen her or her son in several months and had assumed that they were doing fine financially, as finances had never been a concern when I asked in the past. However, our ED Navigator did a screen and found that she was running into some financial issues. In response, the ED Navigator helped connect the patient to SNAP, as well as address some of her other financial stressors. After the fact, I received an in-basket message through Epic telling me that she had this need and had been connected to the appropriate services. This helped me start a conversation with her about it the next time I saw her. It was a beautiful way of having somebody who is much more adept at connecting patients with social services take care of that difficult legwork, and at the same time it provided me with some extra insight into the other dimensions of this patient’s life, which allowed me to connect with her on a deeper level.”

population health primary care,

Dr. Rebecca Lee, Medical Director for Population Health, North Shore Physicians Group

“Our population health programs have not only made my work easier to do, but they have allowed me to provide the ideal patient experience that I would like to offer. I started practicing medicine 12 years ago and at that point, we didn’t have any of this programming, so seeing the growth of these programs between then and now has been amazing.

The biggest surprise to me was the benefit of having social workers in our offices. As part of the high-risk care management program (iCMP), we were given social work support for our patients, and over time I’ve come to realize I never want to practice without a social worker in my office again. They are truly indispensable in terms of what they can do for our patients. Very frequently, I’ll have a patient in tears over an issue that they’re dealing with, and I can’t tell you how liberating it is to just walk down the hall and into my team’s office to ask for help. From there, the social workers can just take the ball and run with it, getting the patient much-needed resources that I don’t have access to as a PCP. If a patient is dealing with horrible anxiety, depression, substance use disorder, or issues with finding food or housing, they’re not going to be able to take care of their health, so the work that I do is ultimately insignificant if we can’t address those basic needs first—but with the social workers, now we can.”

population health primary care,

Dr. Jonathan Snider, Primary Care Provider, Newton Wellesley Physicians Hospital Organization

“Population health is a seamless extension of my team that helps me manage and track my full patient panel. One thing that the population health team helps us do is use clinical registries to keep track of our patients who need screening tests. We have a dedicated Population Health Coordinator who tracks and reports on overdue and soon-to-be-due critical measures, including A1Cs, lipids and blood pressures, for our at-risk patients. In addition, the Population Health Coordinator helps ensure that my general patient population is up-to-do date on important cancer screenings, such as mammograms and colonoscopies. I receive weekly reports on patients who are overdue for an office visit or who need a visit soon, as well as those who need screenings and labs, which greatly reduces my workload and the burden on my staff.

We have seen firsthand that this program significantly improves the quality of care we provide patients, as well as patient outcomes. There is simply no way I could provide this type of personalized outreach without population health. It sounds like a trivial thing, but even something as simple as maintaining current patient lists, which our Population Health Coordinator also does using our electronic health record (EHR), makes a big difference. It has helped our busy family practice of 9 providers, which serves over 7,000 patients, be more efficient and manage our resources better. We truly could not do our job as well without these invaluable services.”

population health primary care,

Dr. Joseph Harrington, Primary Care Provider at Charles River Medical Associates

“One new population health program that I’m very excited about is the Memory Care Initiative. I see many patients struggling with the symptoms of dementia, and this program is going to help me tremendously with meeting their needs. Whether it’s keeping the patients at home longer or getting them and their families access to the resources that they need, this program will provide a collaborative care approach to the care of patients with dementia, which is becoming increasingly necessary. When I talk about this upcoming program to patients and their families, they just want to know how soon they can be enrolled. I have a sticky note on my computer monitor with the initials of patients that I’m going to sign up as soon as I can, and it grows all the time. The need for a program like this is so great, I must say I haven’t been this excited about a program in a long time.”


Want to share your own thoughts on the impact of population health in primary care? Contribute to the conversation by joining the Population Health Management LinkedIn Group.

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