Population Health Management

Proactive health management with 28% hospital admission reduction and 73% patient engagement.

Business Challenge

An accountable care organization managing 850,000 lives struggles with identifying high-risk patients, coordinating preventive care, and reducing total cost of care while improving outcomes.

Agent Collaboration Architecture

Detailed Agent Workflow

1. Sindhan Discover - Population Insights

• Input: Claims data, clinical records, program histories
• Processing: Identifies care gaps and intervention opportunities
• Output: Gap analysis, cohort identification, success patterns
• Finding: 127,000 patients with preventable high-cost conditions

2. Sindhan Analyze - Risk Stratification

• Input: Clinical data, social determinants, utilization patterns
• Processing: Multi-factor risk analysis across the population
• Output: Risk scores, cohort segments, cost predictions
• Depth: Analyzes 450+ risk factors per patient

3. Sindhan Predict - Health Trajectories

• Input: Patient histories, disease progressions, interventions
• Processing: Predicts individual health outcomes and costs
• Output: Disease progression, utilization forecasts, cost projections
• Accuracy: 88% accuracy in high-cost patient identification

4. Sindhan Decide - Intervention Strategy

• Input: Risk profiles, available programs, resource constraints
• Processing: Optimizes intervention selection and timing
• Output: Personalized care plans, outreach priorities
• Personalization: Unique strategies for 850,000 members

5. Sindhan Execute - Care Delivery

• Input: Care plans, provider networks, patient preferences
• Processing: Coordinates care delivery across settings
• Output: Appointments, reminders, care team coordination
• Reach: Engages 73% of high-risk patients

6. Sindhan Optimize - Program Enhancement

• Input: Outcome data, engagement metrics, cost impacts
• Processing: Continuously improves intervention effectiveness
• Output: Enhanced programs, refined targeting, better timing
• Improvement: 12% quarterly improvement in outcomes

7. Sindhan ROI & Strategy - Value Management

• Input: Quality scores, cost metrics, contract performance
• Processing: Optimizes population health strategy
• Output: Risk contract strategies, care model innovations
• Leadership: Guides transition to value-based care

Implementation Results

Clinical Outcomes

• Hospital admissions reduced by 28%
• ED visits decreased by 34%
• Medication adherence improved to 89%

Financial Performance

• Total cost of care reduced by $142M
• Quality bonuses increased by $67M
• Shared savings of $89M achieved

Population Impact

• Preventive care gaps closed for 67% of population
• High-risk patient engagement increased to 73%
• Patient satisfaction improved by 41%

Key Features

Risk Stratification

• Predictive Risk Models: AI-powered risk assessment
• Social Determinants: SDOH integration and analysis
• Multi-morbidity Analysis: Complex condition management
• Cost Trajectory Modeling: Future cost predictions

Care Gap Analysis

• Quality Measure Tracking: Comprehensive gap identification
• Preventive Care Monitoring: Screening and vaccination tracking
• Chronic Disease Management: Care plan adherence monitoring
• Specialist Referral Optimization: Appropriate care coordination

Patient Engagement

• Personalized Outreach: Tailored communication strategies
• Mobile Health Integration: App-based patient engagement
• Care Coaching: Automated and human coaching programs
• Behavioral Health Support: Mental health intervention

Getting Started

Ready to transform your population health management?