Prioritizing focus across different population health initiatives can be a difficult task without good data on which initiatives have demonstrated success. While most provider organizations look to adhere to evidence-based guidelines, there are few explicit standards for many innovations in care transformation. To make the right investments in population health management, providers should prioritize initiatives that have been proven to move targeted metrics related to cost, quality, and utilization.

The Care Delivery Innovation Reference Guide helps organizations understand the strength of evidence and range of impact of specific population health interventions. The reference guide summarizes the evidence base behind 45 commonly implemented population health interventions.

For each intervention, we've outlined the strength of evidence on whether the intervention reduces cost, inflects utilization, and improves quality, access, and stakeholder satisfaction. Download the Care Delivery Innovation Reference Guide Methodology Overview for more information on the research process.

Use the interactive menu below to browse across all interventions, interventions by patient risk level, or expected impact. You can also download an Excel version of the tool to access all interventions at once.

  Download the methodology

Jump to specific interventions

Click on any of the interventions below to receive a brief description, range of impact, and a summary of best practices for implementation.

Behavioral health

• Integrated behavioral health
• Medication-assisted treatment
• Universal depression screening

Care coordination/management

• Care transition support
• Community paramedicine program
• Emergency department-based navigation
• High-risk care management
• Medication therapy management
• Nurse triage line
• Preferred post-acute care network

Disease management

• Asthma disease management programs
• CHF chronic disease management support
• Chronic depression management support
• Chronic disease management support
• COPD chronic disease management support
• Diabetes chronic disease management support
• Hypertension disease management programs
• Peer mentoring
• Telephonic self-management support

Serious illness care

• Advance care planning
• Family/caregiver support program
• Hospice care
• Palliative care

Patient engagement

• Health literacy support
• In-person health coaching
• Motivational interviewing
• Patient education
• Teach-back

Primary care innovation

• Group visits/shared medical appointments
• Patient-centered medical home
• Super-utilizer clinic

Social determinants of health

• Community health worker program
• Employment/income support
• Food security services
• Language-concordant care
• Mobile health clinics
• Non-emergency transportation services
• Social cohesion interventions
• Supportive housing program

Telehealth

• Remote monitoring
• Self-management mobile applications
• Virtual urgent/primary care

Wellness

• Weight management programs