Population Health Management (PHM)

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Population Health Management (PHM) is a health care discipline focused on improving the health and quality of life for a defined population. It uses strategies such as care coordination, data analytics, risk stratification (high, low, and rising risk), and targeted interventions at the individual, group and community levels.

Why PHM matters: By proactively managing health across populations, PHM helps reduce costs, improve outcomes, and enhance patient experience. It ensures resources are used efficiently while addressing the unique needs of different risk groups.

Example in LTC: In a long term care setting, PHM helps care teams proactively support residents with complex, chronic conditions. By identifying residents at higher risk for hospitalizations-- such as those with heart failure—providers can intervene earlier and more effectively. Using data analytics and risk stratification, care teams can implement targeted interventions to keep residents healthier, including:

  • Medication reconciliation to reduce adverse events
  • Telehealth check-ins to maintain better continuity of care
  • Early symptom monitoring to address issues before they escalate

Together, these approaches help prevent avoidable hospitalizations while improving residents' quality of life and overall care experience.

PHM models differ based on factors such as the level of financial risk, the extent to which payment is tied to quality, reliance on data analytics, and the degree of care coordination.​

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Comparison of PHM Models​

​For more information about PHM models, check out Provider Magazine’s Spring 2026 Issue: Finding the Right Value-Based Payment Model.

A bundled payment is a single payment for all care and services provided for a specific patient performed by multiple providers for a single procedure or medical condition over a specified period of time. Focused on certain conditions, bundled payments tend to have a specialty/hospital-centered approach.

TEAM

  • The Transforming Episode Accountability Model (TEAM) is a mandatory model (2026-2032) that holds selected hospitals responsible for the cost and quality of care for five surgical procedures – from surgery through 30 days post-discharge.
  • It aims to improve care coordination, reduce avoidable readmissions, and incentivize value-based care through episode-based payment and performance metrics.
  • SNF/PAC providers can participate as model collaborators in order to share in potential hospital savings. Review AHCA/NCAL's TEAM Toolkit for more information on how SNF/PAC providers can engage with TEAM.
  • If TEAM proves to be successful, CMS may add additional episodes for inclusion.
  • Related media: AHCA Announces New Provider Toolkit for CMMI Model TEAM

CARA

  • The CMS Risk-Administered Arrangements (CARA) Initiative introduced standardized episode-based risk arrangements between ACOs and specialists.
  • The LEAD model will feature CARA for the first time, beginning with fall prevention.
  • The initial fall prevention episode provides a structured intervention option that Global Risk LEAD ACOs can select, provided the episode is in response to beneficiary needs.
  • CARA-related episode costs will be factored into the ACO’s expenditures during LEAD’s financial settlement and CMS will calculate payments to determine performance. ​ 

MAHA ELEVATE

  • MAHA ELEVATE (Make America Healthy Again: Enhancing and Evaluating Value-Based Approaches Through Evidence) will provide up to 30 cooperative agreements to organizations and their partners to test lifestyle and functional medicine interventions not currently covered by Medicare FFS in 2026 and 2027.
  • These evidence-based whole-person care approaches will supplement the medical care received by Medicare FFS beneficiaries.
  • This model offers highly experienced assisted living providers an opportunity to participate directly or via partnerships with organizations delivering whole-person, lifestyle-focused care.
  • Providers can leverage AL infrastructure to scale existing evidence-based interventions that support chronic disease prevention and functional wellness.
  • Related media: CMS Introduces MAHA ELEVATE Model to Address Chronic Disease through Whole-Person Care

GUIDE

  • GUIDE (Guiding an Improved Dementia Experience) is a voluntary model designed to improve care for people living with dementia and their caregivers.
  • The model focuses on comprehensive, person-centered care coordination, caregiver support, and access to community-based services to enhance quality of life of people with dementia and their caregivers.
  • Assisted Living providers can participate as a GUIDE Partner Organization to help the GUIDE Participant meet care delivery requirements (e.g., by providing respite care).
  • There is no limit on the number of GUIDE Participants that a Partner Organization can support.
  • Related media: CMS Releases New Dementia Care Model GUIDE to Better Support Caregivers

ASM

  • The ASM (Ambulatory Specialty Model) is a mandatory model starting in 2027 that would hold outpatient specialists accountable for the quality and cost of services related to heart failure or low back pain.
  • It aims to improve chronic disease management, reduce avoidable hospitalizations, and increase coordination with primary care providers, and improve interoperability and electronic sharing of health information.
  • ASM does not directly impact SNF/PAC providers. However, it may have indirect implications for care coordination and future model expansion to other conditions commonly managed in SNF/PAC  settings, if the model proves successful. ​

Accountable Care Organizations (ACOs) are networks of physicians, hospitals, and other health care providers that voluntarily come together to coordinate care and manage the total costs of care for a defined population. ACOs share in the financial risks and rewards based on performance against quality and cost benchmarks as well as patient outcomes. ACOs have a primary care-centered approach and include all conditions. There are multiple Medicare ACO models with varying degrees of risk, as well as Medicaid ACOs.

ACO REACH (ends December 31, 2026)

  • The ACO REACH (Accountable Care Organization Realizing Equity, Access, and Community Health) model is CMS's evolution of advanced risk-sharing arrangements, replacing the Global and Professional Direct Contracting model.
  • It uses prospective, population-based payments (capitation) tied to quality and cost benchmarks, with a strong emphasis on health equity and care for complex, chronically ill, and high-needs beneficiaries.
  • ACO REACH includes a High-Needs Population track, similar to PACE, for organizations serving dually eligible and medically complex individuals.

LEAD (starts January 1, 2027)

  • The LEAD (Long-term Enhanced ACO Design) model will succeed ACO REACH in 2027, offering a 10-year performance period, more predictable benchmarking, and enhanced beneficiary engagement incentives.
  • LEAD aims to broaden participation among smaller, independent, and rural providers while maintaining capitated payment structures and accountability for total cost and quality outcomes.
  • Related media: CMS Releases LEAD Model Request for Applications

LTC-FOCUSED ACO MODEL (AHCA/NCAL PROPOSAL)

  • In 2023, most nursing home residents (>70%) were not assigned to an ACO, despite 100% meeting ACO alignment criteria (MedPAC, 2025, Ch. 5, p. 258).
  • AHCA's ACO Workgroup recommends creating a specific LTC-Focused ACO or a track within LEAD with the facility as the participant (facility TIN used for alignment).
  • Eligibility assessed monthly via the LTI flag to comprehensively capture the entire ACO-eligible LTC population.
  • The proposal also includes several financial, quality, technology, and prevention/chronic disease management recommendations, including:
    • Flexible risk-sharing options, concurrent risk adjustment, and updated benchmarking;
    • A streamlined set of LTC-centered quality measures;
    • Incentives and support for interoperable technology adoption; and
    • Incentives for prevention and chronic disease management models that link across the care continuum.
  • ​Read the whitepaper here.
Special Needs Plans (SNPs) are Medicare Advantage plans (Part C) that limit enrollment to subgroups of Medicare beneficiaries with specific needs (i.e. institutionalized individuals, dual-eligible individuals, or individuals with cert​​ain chronic conditions as specified by CMS).

  • PROVIDER-LED SPECIAL NEEDS PLANS
    • ​SNPs offer services tailored to the specific population under a National Committee on Quality Assurance-approved model of care and must provide Medicare prescription drug benefits (Part D).
    • “Provider-led" or “provider-owned" are SNPs where a provider owns some sort of equity or ownership stake in the plan.
    • Provider-led I-SNPs are led by SNF/NFs or other LTC providers.
    • Provider-led I-SNPs use nurse practitioners to deliver more proactive, coordinated care at the bedside.
Total Cost of Care models aim to manage healthcare costs by promoting coordinated care, improving quality, and enhancing patient outcomes. Since the model focuses on overall costs and quality, providers in TCOC models are incentivized to collaborate with other providers to ensure that robust care is delivered effectively. They differ from bundled payment models because they provide a global budget instead of a budget for a single episode of care.

AHEAD (Select States ONLY)

  • The AHEAD (Achieving Healthcare Efficiency through Accountable Design) model is a voluntary, state-based total cost of care (TCOC) model that runs from 2024 to 2035.
  • It aims to curb healthcare cost growth, improve population health, and advance efficiency by aligning multiple payers (Medicare, Medicaid, commercial payers), implementing hospital global budgets, and increasing investment in primary care.
  • States participating in AHEAD include Maryland and Vermont (Cohort 1); Connecticut and Hawaii (Cohort 2); and Rhode Island and sub-state regions in New York (Cohort 3).
  • SNF/PAC services are not included in the TCOC of model, but providers may experience tightening networks and faster discharges as payers work to contain all-payer, primary care and hospital cost growth.

GEO AHEAD (Launching 2028)

  • The Geo AHEAD program is a new ACO track within AHEAD that includes geographic-based alignment, expanding TCOC accountability to otherwise unattributed Medicare fee-for-service (FFS) beneficiaries within AHEAD regions. 
  • The model includes two four-year contract periods between 2028 and 2035. 
  • Model participants include non-provider led organizations (e.g., health plans, technology companies), Hospital Global Budget (HGB) providers, and Primary Care AHEAD (PC AHEAD) providers.
  • Unassigned beneficiaries within AHEAD regions (currently Maryland, Vermont, Connecticut, Hawaii, Rhode Island, and certain areas in New York) will be attributed to a Geo Entity (model participant) once the program launches. CMS is expected to release further guidance for the Geo AHEAD program prior to its launch in 2028.
  • Related media: CMS Announces Major Changes to AHEAD Model Design

ACCESS

  • ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) is a 10-year (2026-2036) voluntary model that tests technology-enabled care and Outcome-Aligned Payments (OAPs), offering monthly fixed payments tied measurable health improvements and cost reductions.
  • The model focuses on managing chronic conditions across our tracks – cardio-kidney-metabolic (CKM), early CKM, musculoskeletal pain, and behavioral health – while requiring electronic care plans and transparent reporting.
  • This model incentivizes delivering technology-enabled care to patients with chronic conditions to improve health outcomes.
  • SNF/NF and AL providers should be familiar with this model, since Medicare beneficiaries can voluntarily align to an ACCESS track.
  • Related media: CMS Launches ACCESS Model to Improve Chronic Care in Medicare FFS Through Technology

WISeR

  • WISeR (Wasteful and Inappropriate Service Reduction Model) is a voluntary model running from 2026 to 2031 in six states, aimed at reducing low-value and clinically unsupported services in Medicare FFS.
  • It uses AI, machine learning, and clinician review to streamline prior authorization and pre-payment reviews for select items and services identified as prone to fraud, waste, and abuse, improving care appropriateness while lowering costs.
  • This model focuses on a specific subset of items/services: skin and tissue substitutes, electrical nerve stimulator implants, and knee arthroscopy for knee osteoarthritis.
  • Since model participants are limited to technology companies, and services are typically provided in acute care settings, SNF/PAC providers are not directly impacted. However, if WISeR proves to be successful, it may be expanded to include other services covered by Medicare.
  • Related media: Important Medicare Updates

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‭(Hidden)‬ Media Coverage: Medicare Advantage and Population Health Management
  • For individuals with one or more CMS-approved chronic conditions.
  • 2026 Outlook: 556 C-SNPs plans offered (+42% from 2025).
  • Most common plan types focus on cardiovascular disease, chronic heart failure, diabetes, chronic kidney disease, and chronic lung disorders. 
  • For individuals enrolled in both Medicare and Medicaid.
  • 2026 Outlook: 1085 plans offered (+15% from 2025).
  • Main plan types include Coordination-Only (CO), Highly Integrated (HIDE), and Fully Integrated (FIDE).
  • In 2026, nearly all Medicare-Medicaid Plan (MMP) demonstrations have transitioned to D-SNPs.
  • For Medicare beneficiaries living or expected to live in nursing facilities for 90+ days (FI-SNP/HI-SNP), or individuals living at home who meet a nursing facility level of care (IE-SNP).
  • I-SNP offerings declined by 5% in 2026, with 156 plans, primarily due to large insurer-based plans exiting the MA marketplace. However, estimates indicate that provider-led plans are up 2%. 
  • 2026 outlook: 156 plans offered (-5% from 2025). Provider-led I-SNPs continue to grow (+2%) despite broader market contraction. They comprise 41 percent of the market share of I-SNPs, covering over 51,000 nursing home residents.
  • Research continues to show I-SNP enrollment is associated with reductions, unnecessary hospitalizations, pressure ulcers, and fall injuries, compared to Traditional Medicare, and non-I-SNP Medicare Advantage (MA) plans (ATI Advisory, 2025)
  • MedPAC's June 2025 Report to Congress includes a comprehensive chapter on I-SNPs, including a section examining provider-led I-SNPs.
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​​​PHM Council


In 2019, AHCA/NCAL formed the Population Health Management Council to convene and support long LTC providers who are leading in PHM initiatives through advocacy, education, and quality improvement data. Along with AHCA/NCAL provider members, there are organizations whose sole or primary purpose is to partner with LTC providers to support LTC provider ownership interests in PHM models. AHCA/NCAL has four such Council Partners, and more information about each is available below. 


American-Health-Plans      

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STAFF CONTACT
Vice President of Population Health and Reimbursement Policy

Population Health Policy Analyst​

PHM Innovation Lab
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The PHM Innovation Lab offers foundational resources designed to introduce AHCA/NCAL assisted living, nursing facility, and intermediate care facility members and their staff to the wide array of PHM models available and how these models can better serve LTC organizations, residents, and families.

Member Resources