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.

Population Health Strategic Plan Summary

Health Partners of New Hampshire, Inc. (HPNH) is a Physician Hospital Organization (PHO) consisting of almost 700 participating members from both employed and independent practices. Clinical integration is the foundation of HPNH. By promoting effective patient care and provider communication, the organization continues to optimize clinical care that improves outcomes for all patients in our community.


The HPNH strategic plan strengthens the organization’s continued population health efforts. Our plan creates a sustainable framework that combines the strength of Mass General Brigham (MGB) population health expertise, while building upon existing Wentworth-Douglass Hospital (WDH) population health programming. It supports and enhances current programs and services, while creating new opportunities for innovation. 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.

The plan is centered around four main domains.

·         Clinical support and programming

·         Value based care success

·         Innovation

·         Equitable care

Each domain contains goals designed to meet the current and future needs of the populations served by the PHO. Enhancing existing clinical programs, creating new programs for patient outreach, using technology to spur innovation, and providing cost effective care are some of the goals expected to be met. Success in the strategic plan initiatives will create a sustainable population health infrastructure that promotes clinical excellence and financial stewardship, while supporting the PHO’s commitment to exceptional patient care for everyone we serve.

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.