Population Management

Population management begins with the identification of populations who are not achieving clinical goals in their region. The population in need is systematically segmented into well-defined “Populations of Focus” (PoFs), each with its own risk scale and requirements.

The RITZ becomes the voice of these patients. Then, working with partners in the region, accountability is assigned, and the missing coordinated services are put in place.

Design in Stages

Design in Stages refers to coordinated services being tailored to the needs and situations of the local population groups. This is made possible through the nationally recognized and standardized medication management called Comprehensive Medication Management (CMM). This professional leads in their set of skills and knowledge to teach as an innovation and spread as a breakthrough in delivery system design. CMM is a critical component to each stage of design. Development happens in three stages – pilot, prototype, and scale up:

AIMM introduces Regional Integrated Transformation Zones

Community Investment Prospectus

• Pilot Stage: Community based organizations are funded to work with the client groups that represent the population at risk. The scale and specific needs of the population are estimated. The objective is to understand their situation and needs in order to design an effective medication care coordination system. 
• Prototype Stage:  Community based partners collaborate in the design, build out and operationalization of the needed medication care coordination systems. This prototype system operates at limited capacity for the PoFs, while partners engage potential payers to establish value-based payment agreements. 
• Scale Up Stage: Under value-based agreements, providers and payers scale up operations to serve the entire PoF. The effort expands partnership and sponsorship relationships to reach full scale within the region. 

Over time this process produces medication care coordination for all groups in the high-risk populations. It is estimated that each three-stage cycle can take several years to go from pilot to full scale.  

Concurrent Change at Three Levels

The RITZ calls for concurrent change at three levels:

• Service Delivery Operations
• Financial Agreements
• Executive Leadership

In order to fill the gaps in the regional health care system, partners come together and work collaboratively at each of the three organizational levels.