Population Health

Optimal Patient Care – Quality Outcomes - Clinical Integration – Population Health Management

The 2022 Quality Program continues and is supported by the WDH Population Health Department.  PHO providers chose various performance improvement projects including diabetes bundle, increased hospitalists patient visitation, tracking cosmetic injectables, screening for urinary incontinence, monitor/follow-up of diagnostic breast imaging orders, access for patient appointments, improved AJCC staging documentation in Medical Oncology, etc. The PHO also has commercial contracts that include quality programs for shared savings, care coordination, hospital pay for performance, and Medicare Advantage quality programs.

2022 Population Health Strategic Plan Summary

Health Partners of New Hampshire, Inc. (HPNH) is a over 600 member Physician Hospital Organization (PHO) consisting of Wentworth-Douglass Hospital (WDH) and participating providers. The organization has the following primary mission. 

  • Optimize patient care quality and cost, while promoting effective patient and provider communication. We develop reliable clinical processes to improve outcomes for all patients in our community, while achieving fair and equitable reimbursement for the healthcare services provided.  Clinical Integration is the foundation of HPNH.

A strategic plan was developed to strengthen the organization’s continuing population health efforts. Our strategic plan creates a sustainable framework that builds upon the existing Wentworth-Douglass Health System (WDHS) population health program. It will support and enhance current programs and services, while creating new opportunities for success. The plan recognizes the unique role providers play in this evolving environment, while also recognizing the need for fiscal responsibility in both programming and services.

Health Partners of New Hampshire continues to deliver high quality care. This success builds on the previous quality projects and clinical integration model, while connecting and supporting our practices for future patient-centered quality advancements.  

As we advance our approach to patient centeredness, our clinical integration framework includes patient care delivery transformation and common quality metrics across our provider community while leveraging technologies to support practice workflow.  This foundation represents our patient focused data driven approach while being supported by evidence-based practices.

As part of this transition, future quality deliverables will focus on the following items for all PHO practices in order to meet the needs of our patient community.

Accessibility: Telehealth or the practices ability to connect with patients (audio or visual) remotely if patients are not able to access in-person care.

Clinical Measures: Developing measurable shared metrics and processes to improve patient experience, health of populations and cost reductions.

Communication: Building methods to ensure effective communications for patient care across the continuum.


Three Core Principles Drove Plan Development

  • Promote continued alignment of WDHS resources to achieve the highest possible level of population health success.
  • Create alignment with Partners HealthCare System (PHS) and Mass General Hospital (MGH) population health activities, resources, and objectives.
  • Support the organizations goal of becoming a regional healthcare hub for the greater seacoast communities.

We also recognized four constraints that limit our ability to execute some population health programs. These are local and national environmental factors that health systems have minimal opportunity to change.

  • Fee for service (FFS) payment models impacting utilization and revenue
  • Managing multiple, misaligned, payer incentive programs
  • Federal healthcare policy uncertainty affecting healthcare funding and coverage
  • Technology constraints

Our strategic plan gives priority to those activities the health system can control, are important for current and future success, and create a sustainable infrastructure. Two broad areas covered in this plan include

1. Infastructure

A sustainable, cost-effective population health infrastructure is vital to our program’s success. We will create and enhance our infrastructure in the following areas.

  • Population health governance
  • Financial stewardship
  • Analytics
  • Communications
  • Internal and external relationship development

Over the coming year, eight targeted infrastructure objectives will be completed that position WDHS for future population health success.

2. Clinical and Quality Programs

Exceptional clinical and quality programs are also an important strategic objective. WDHS will continue to innovative and enhance clinical care in the following domains.

  • Care management
  • Care resign and innovation
  • Quality

Over the coming year, five targeted clinical and quality objectives will be completed that position WDHS for future population health success.


Our strategic plan recognizes the breadth of clinical activities and financial stewardship necessary for population health success. Focusing our resources thoughtfully will help us achieve our goal of providing high quality, cost-effective care for all patients.