Population Health Management

Driving better outcomes through smarter health management

Population Health Management (PHM) offers a transformative approach to healthcare delivery by focusing on improving outcomes for defined populations while optimising resource allocation. Our approach supports you move from reactive care to proactive health management, through the powerful combination of data-driven insights, AI-powered predictive analytics, and value-based payment models.

In the Gulf region, where healthcare systems are going through transformative change, PHM provides a framework to address the growing burden of chronic diseases, reduce unwarranted variation, and enhance overall system sustainability. We help organisations in developing and implementing comprehensive PHM strategies that improve health outcomes, enhance patient experience, and achieve greater value from healthcare investments.

Our Approach

We use data-driven approaches to transform care for defined populations and improve long-term outcomes. Our approach to population health management integrates value-based principles and strategic commissioning:

  • Population segmentation: We develop comprehensive insights into population health needs and risks through sophisticated population segmentation and analytics
  • Intervention design: We help you develop targeted, evidence-based interventions for different population segments, focusing on high-risk groups
  • Value-based frameworks: We design payment models and incentives that align provider behaviour with desired outcomes and population health goals
  • Implementation planning: We provide practical support for implementing new care models and payment systems across organisational boundaries
  • Outcomes measurement and evaluation: We establish robust measurement frameworks to track intervention impact, assess value, and drive ongoing improvement
  • Sustained impact: We create lasting impact by transferring knowledge and skills to local teams for long-term success and reducing dependency on external expertise

Infrastructure, intelligence, interventions, incentives

CF are experts at population health management with an approach that leverages five elements of intervention

1. Identify

Identify key people within each cohort as defined by set criteria (using data and case finding)

  • Using data insights from population segmentation and risk stratification to prioritise individuals before risk increases
  • Professionals may also case find additional people as they present

2. Enrol

Proactive reach out to cohort to engage into the programme and triage onto the right pathway;

  • Proactive reach out to identified people to ensure they enter right pathway
  • Invite using text/ email/call
  • Enrol in session
  • May need to work with individual and their family/care

3. Assess

Deliver a person-centred single trusted holistic assessment of a person’s needs that covers all needs;

  • Assessment may vary based on requirement
  • Diagnostic tests may be required
  • Fuller assessment of needs may be holistic
  • Identification of priorities to address

4. Protocolized care

Protocolised care to address needs with professionals involved in person’s care;

  • Protocolised care collaborating with key professionals and partners defining who will do what
  • Management by thresholds where appropriate
  • Identification of escalation needs

5. Manage

Ongoing effective case management of person with a single ‘point person’ (the care coordinator);

  • Planning, co-ordinating and reviewing the ongoing effective case management of a person
  • Tracking progress at individual level

Our offers

  • Population health needs assessment and risk stratification
  • Segmentation and targeting of high-risk groups
  • Variation analysis to identify improvement opportunities
  • Predictive modelling to anticipate future healthcare needs
  • Strategic commissioning frameworks based on population insights

  • Design of value-based payment models tailored to local contexts
  • Development of incentive structures aligned with outcomes and local constraints
  • Implementation of governance frameworks to support value-based care
  • Creation of measurement systems to track value and impact
  • Operational process design to embed value-based care principles

  • Evidence-based intervention development for high-risk populations
  • Integrated care pathway design across primary, community and acute settings
  • Prevention and early intervention programme development
  • Self-care and patient activation initiatives
  • Digital health solutions to support population health management

  • Development of outcomes and economic impact dashboards
  • Implementation of continuous improvement cycles for PHM initiatives
  • Return on investment analysis for population health interventions
  • Refinement of PHM strategies based on performance data
  • Benchmarking against regional and international standards

Our credentials

Case Study

Developing stroke care models for system transformation

Case Study

Improving value for money and care pathways for a large GCC health provider

Ton speak to one of our specialists about Population Health Management, contact us today.