In a pediatric medical home, managing a patient population means monitoring and anticipating the health care needs of patients—as a group—in order to assure they receive the services they require. ​​​​​

For practices just beginning the medical home transformation process, managing your patient population can start by implementing small changes (such as a reminder system of procedures for high-risk patients) and grow into a larger tracking system, such as a patient registry. 

A patient registry allows a practice to organize their patients by specific characteristics, such as a chronic disease or condition. By organizing a patient population in this manner, a practice can keep track of necessary labs and preventive services for such patients. 

For example, a reminder system for flu shots for high-risk patients (such as those with asthma) can eventually grow into a patient registry for children and youth with asthma. This will allow a practice to proactively care for its patients with asthma, thereby providing comprehensive, coordinated, preventive health care that is critical to the function of a medical home.​​

Jennifer Lail, MD, FAAP | Cincinnati Children's Hospital Medical Center​


Patient registries are effective ways to measure and document care and can help to monitor and evaluate practice performance.​

 Characteristics of Patient Population Management

Your practice manages its patient population successfully if it:

  • Provides and documents planned, proactive, comprehensive care by:
    • ​Documenting all patient encounters, including office visits, phone calls, and email communications
    • Systematically planning for patient encounters (by preparing patient’s medical records before the encounter, discussing the case with the health care team, etc)
    • Incorporating reminders for age appropriate developmental screenings and risk assessments
    • Incorporating evidence-based practices and guidelines (such as a periodicity schedule) when providing care to patients
    • Identifying bottlenecks in patient flow and using this information to improve office wait times
    • Developing and maintaining procedures for pediatric patients in case of a medical emergency
  • ​Develops and utilizes at least one system of accessible and clinically useful information for a patient population, and this system:
        • ​​​Aligns each patient with a primary care clinician or physician-led team
        • Identifies patients with special health care needs
        • Is used to identify and/or proactively remind clinicians and patients/families of needed preventive services (such as immunizations)
        • Tracks laboratory tests, procedures, referrals, protocols, and recommended actions in partnership with the patient and family
        • Is used routinely by appropriate care team members who are trained to use the tool
        • Is kept up to date​

 Tools and Resources

These tools may help manage patient population within your practice:

Pediatric Care Plan
Pediatric Care Plan in Spanish​​
Four-page customizable form for a pediatric care plan. Allows for inclusion of all pertinent current and historic, medical and social aspects of a child and family's needs.

Action Plan Template
Action Plan Template in Spa​​​​nish
One-page customizable document which allows the clinician and family to list next steps in the care process while detailing who is responsible for each referral, test, evaluation or other follow up activity.

Emergency Plan Template
Emergency Plan Template in Spanish
Blank Emergency Form
Two customizable forms which provide suggested disease management actions in case a patient has a medical emergency.

Further links:

Constructing an Asthma Registry
Step-by-step instructions to create a registry for children with asthma using Microsoft Excel or Access.

Creating Patient Registries
This document, created by the Agency for Healthcare Research and Quality, serves as a guide to the design, implementation, analysis, interpretation, and evaluation of the quality of a patient registry.

Registries Made Simple
Detailed step-by-step instructions on how to set up a patient registry from the journal of Family Practice Management.

Periodicity Schedule
This evidence-based schedule guides pediatric clinicians in necessary screenings and assessments recommended during each well-child visit from infancy through adolescence.

Training Courses for Excel
Creating a patient registry does not require the presence of Electronic Health Records (EHR) within a practice. Practices can use Excel and other easily accessible computer programs to organize patient data. Microsoft Excel tutorials can assist practices to create patient registries.

Patient Population Management Through Empanelment
Empanelment is one strategy to effectively manage a patient population by assigning individual patients to specific primary care providers. This ensures continuity of care. This collection of resources includes an implementation guide to assist with this strategy.

Improving Preventive Care In Your Office: Tools for Office Improvement
​These Bright Futures Training and Implementation Resources provide tools for practices to establish preventive services prompting systems and establish recall and reminder systems in order to increase the efficiency of population management within a practice.

 Tools and Resources from the American Academy of Pediatrics

APEX Digital Navigator
This modular, web-based software application available from the American Academy of Pediatrics delivers in-depth, step-by-step instructions through practice transformation into a medical home.

EQIPP: Medical Home
​The American Academy of Pediatrics offers an EQIPP course, Medical Home, which guides users through the detailed quality improvement process necessary to undergo the pediatric medical home transformation.