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Teaching Residents Population Health Management

Year Published: 2019
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Teaching Residents Population Health Management

This publication explores best practices in population health management (PHM). It presents profiles of successful practices at primary care residency programs to help residency program directors incorporate PHM principles into education programs.

Teaching Residents Population Health Management
Year Published: 2019
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Designed for residency program directors, designated institutional officials (DIOs), deans, community benefit officers, quality improvement officers in hospitals, and others interested in best practices in primary care residency teaching practices. 



Population health management (PHM) refers to a systematic approach to ensuring that all members of a defined population receive appropriate preventive, chronic, and transitional care. PHM also helps providers identify and address health care inequities among subgroups within that population.

PHM is one building block of high-functioning, high-value primary care but is inconsistently understood and operationalized in practice and training settings. In June 2018, the AAMC sponsored a meeting to describe PHM best practices in primary care residency teaching practices, with an emphasis on how residents are trained. This report summarizes the components of PHM and offers vignettes describing how several of the seven participating residency programs implemented these components.

Meeting participants identified 10 foundational elements and key activities that constitute a comprehensive PHM system:

  • Data infrastructure
  • Team-based care
  • Community engagement
  • Panel management
  • Patient risk stratification
  • Care management
  • Self-management support
  • Complex care management
  • Addressing social determinants of health
  • Ensuring health equity



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More Information
Edition: First Number of Pages: 50 Year Published: 2019