Population health management (PHM) is a refined model of care delivery involving a systematic effort to assess the health needs of a target population and to provide services to maintain and improve the health of this population. population (Sg2 Health Care Intelligence, 2014, p. 1). As health systems look for ways to reduce expenses, MPS may be considered. However, confusion and skepticism towards PHM is present. The MPS framework includes a multi-step approach consisting of four steps similar to the public health model. The framework is composed of: 1) population identification; 2) health assessment; 3) risk stratification; and 4) health continuum. The health continuum helps determine whether an individual within a population is at low or no risk, moderate risk, or high risk for the selected health complication to be treated. Depending on where the individual falls on the continuum or the magnitude of risk ultimately determines the type of health management intervention to be used. Health management interventions include preventive services, lifestyle coaching, traditional care, complex care management, palliative and end-of-life care (Sg2 Health Care Intelligence, 2014, p. 2) . PHM is different from what most health systems do today. Health care organizations involved in population health must be concerned with all determinants of health, including environmental, social, economic, and individual factors. This type of care does not fall within the domain of traditional medicine and it is very difficult for health establishments to implement this strategy alone. PHM is recommended by Sg2 Health Care Intelligence (2014) to achieve clinical alignment and resource efficiency (CARE).????????? It's about networking and partnering with ...... middle of paper ...... on rates and costs. Telephone education, a core activity of many MPS programs, can promote self-care and patient satisfaction. Remote patient monitoring technology appears effective in managing chronic diseases and overcoming the lack of current data. These technological devices can monitor blood sugar and blood pressure, provide real-time information on health status and indicate intervention. Also, the use of social networks has been successful. Many organizations like Weight Watchers and Alcoholics Anonymous have shown how peer support groups can shape behavior. These types of achievements provide positive reinforcement for the development of PHM (Sg2 Health Care Intelligence, 2014, p. 5). Whether or not an organization decides to use the PHM model, it must possess certain characteristics for the change to be successful..