Population Health Management

Committed to improving quality and reducing cost of care.


We consider the Population Health Management Company an integral part of who we are. It provides support, resources and information to physicians, which they use to make better clinical decisions – leading to improved quality and efficiency. By providing these services to both our Physician and Hospital Networks, we’re able to better delegate care management, optimal contract performance, utilization and quality management, and achieve clinical integration.

Converging data, technology, and resources through
Population Health Management.


Population Health Management supports improvements in health care system. This allows us to provide better quality and more efficient care.

  • We believe the best care and utilization management approach involves partnering with physicians and their teams to create and follow pathways that put patients first
  • By managing 400+ staff members, we support physician practices with care coordination, transitions, navigation, quality improvement, and advanced analytics
  • State-of-the-art information technology ensures that our teams are equipped with risk stratification tools, EMR and claims data
  • We leverage the capabilities of the Texas Health and UT Southwestern acute care hospitals, with support from PHSC dedicated to population health management
Our mandate to better coordinate and reduce cost of care
network of partners
patient access and engagement
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care management
IT connectivity

Working together to close gaps in healthcare.


For providers, understanding the full scope of patient care needs has been daunting for a number of reasons. There are gaps in processes and a lack of digitized health data among other things. As a result, it’s hard to gather what might have the greatest impact on the population as a whole, as well as on individual patients.

But our approach is different. These are the three areas that make up the population health and clinical integration performance analytics.

Analytics Architecture – built to include claims-based analytics, supplemented by real-time (or near real-time) physician practice EMR data, scheduling data, and hospital ADT information (including non-SWHR hospitals)

Opportunity Analysis – identifying patients that need PHSC support services, including high-risk care management, preventive care, incorporation into disease management programs, referral guidelines, and utilization management programs

Direct Patient Engagement – ability to directly engage patients through personal and automated means to track adherence to care management protocols and provide additional support services

How we support your needs:

We prefer a coordinated approach with an employer through benefit design. This includes requesting claims and pharmacy data for the past two years from an employer group. By using a predictive modeling tool, we can assess individuals with chronic diseases and identify the best Care Management program based on their risk level.


Using data to improve physician performance.


Population Health Services provides us with a unique health management system that allows information and improvements to be rapidly scaled across the network.  An extensive data repository (from physician EMRs that now include nearly 3 million unique D/FW patients), data integration, and analytics all feed into a robust health information exchange system that helps physicians improve performance.

Using information and resources from Population Health Services, individual physicians and physician groups are supported in improving quality and safety, as well as reducing the total cost of care. This supports opportunities to build improvements of individual providers and groups, as well as the overall performance of the Physician Network.

Here’s how we’re working to make healthcare better.

Support And Services

Patient Navigation

Dedicated patient navigation teams help ensure patients are seen by the right provider. We have more than 200 employees in primary care practices and central call centers to ensure appropriate care transitions occur in a timely manner. This also ensures clinical information is transmitted in an efficient manner.

These programs work closely with hospital care transition teams and care management teams to ensure patient needs are met, and to support physicians and their care teams.

Care Management

Individual patients are not only members of multiple populations, but move among different cohorts as circumstances change. Because of this, we need both the close-up view of individuals and the wide-angle perspective of entire populations to see and manage these cohorts clearly and effectively. This provides added services to patients with highly complex conditions, chronic diagnoses, multiple comorbidities and those that may need help adhering to treatments.

Care Coordination

Our Care Coordination team includes skilled care managers, social workers, and pharmacists, who help identify patients with complex and chronic conditions. These experts collaborate to fill gaps between primary care services and patients’ care, offering resources related to coordination among multiple doctors, access to resources, long-term support, and remote monitoring.

Post-Acute Care

Post-acute care is a major factor in our costs and outcomes which is why we’ve established processes to mitigate/reduce the total cost of care for these patients. 

We offer a care model with providers selected to deliver care that even includes robust home health care services. This enables us to deliver the right level of care for the right reasons to patients both in and out of the hospital.