Population Health Analytics

Many population health strategies rely on identifying high-risk or high-cost members. But broad cohorts can be difficult to operationalize — often leading to overlapping outreach, diluted focus and missed opportunities to intervene effectively.

Johns Hopkins Health Plans took a different approach.

The team shifted from broad risk identification to a more focused strategy centered on patient-level impact. Instead of asking who is high risk, they prioritized where intervention could make the greatest difference.

Members were identified across three key dimensions: clinical complexity, true intervention opportunities and concerning health trajectories. By creating mutually exclusive cohorts aligned to specific actions, care teams could concentrate efforts where they mattered most — without duplication.

The result: a more sustainable framework that improved outcomes, enabled more efficient use of resources and supported success in value-based care.

Read the full case study to see how this approach was implemented — and the results it delivered.

To learn more about how the ACG System can support your organization, visit hopkinsacg.org or contact us at acginfo@jh.edu. If you are a current ACG System customer, please reach out to your Account Manager.