Population Health Services Organization

Our vision is to enable health care providers and patients in our Accountable Care Organization to achieve the best outcomes in the nation.

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Who we are

Message from Mallika Mendu MD, MBA, Chief Population Health Officer

The Mass General Brigham Population Health Services Organization (PHSO) is responsible for improving care for the 650,000 patients we serve through value-based care payment models. These models support our mission to enhance quality, promote health equity, and achieve better clinical outcomes.

We’ve established collaborative, risk-based agreements with Medicaid, Medicare, and other health insurance payers. These agreements provide health insurance coverage that include performance standards for quality and cost, helping us deliver greater value for patients while supporting the long-term sustainability of our health system.

Value-based care gives us the opportunity to invest in better care for our patients. When we meet our goals, we’re able to reinvest in services, programs, and innovations that improve the health of the communities we serve.

Our patients are at the center of everything we do. The PHSO works closely with frontline health care providers across the system, including care managers that help patients stay healthy and out of the emergency room, pharmacists that call patients to make sure they’re taking the medications they need, and population health coordinators and community health workers that help patients manage chronic conditions, making sure they have tools like blood pressure cuffs and understand how to use them.

We also partner with teams across Mass General Brigham, including leaders in primary care, the Office of the Chief Medical Officer, Community Health, and Healthcare at Home. Together, we work toward a shared goal of delivering the right care, at the right time, in the right place.

Our team’s guiding principles are to:

Keep patients healthy and at home as long as possible
Better understand our patients’ health needs to guide timely and effective care
Use performance and benchmark data to identify and act on opportunities for improvement
Strengthen our performance in risk contracts so we can reinvest in our patients by partnering with providers across our hospitals and clinics to develop impactful interventions

Our value

In addition to improving patient care, the PHSO helps maximize our health care payer contracts to result in shared savings for Mass General Brigham. For example, in 2023, the PHSO’s programs and services generated $36.2 million in shared savings through the Medicare Shared Savings Program.

The PHSO team works across departments to streamline efforts, reduce duplication, and create alignment with system-wide goals. Key collaborations include:

Office of the Chief Operating Officer: Together, we develop focused approaches to ambulatory care with the goal of reducing avoidable admissions and emergency department visits, shifting care to community clinical sites and increasing inpatient capacity. We also implement ambulatory quality operations to achieve systemwide quality and equity goals.
Care Continuum Management Team: We partner on post-acute care strategies and transitional care efforts to ensure patients move safely and efficiently across care settings.
Mass General Brigham Health Plan: We support patients through complex care needs and enable continuity of care across the system.

What we do

The PHSO identifies, develops, implements, and evaluates innovative care programs that improve quality, promote equity, and prevent avoidable hospitalizations, emergency department visits, and skilled nursing facility admissions or readmissions. We also provide patients with more choice in how and where they receive care.

By reducing non-patient-centered use of health care services, especially during a time of limited access and capacity, we increase access to timely care for patients with acute and complex needs.

Care management programs

Patient and doctor looking at prescription bottle

Chronically ill patients with multiple conditions often need extra support to coordinate their care and navigate the system. The Integrated Care Management Program (iCMP), which is for adults and children, and the iCMP Plus Program are designed to support patients with the most complex care needs.

These programs aim to help patients stay healthier for longer by providing the specialized care and services they need to prevent complications and avoid hospitalizations. iCMP offers primary care-embedded, longitudinal care management for patients with complex medical and behavioral health conditions, as well as high patterns of health care use.

Research has shown that iCMP is an effective population health strategy that helps reduce avoidable hospital admissions and lower overall health care costs.

In addition to clinical staff, the iCMP team includes administrative experts who help manage, monitor, and continuously improve these programs.

Quality initiatives

In alignment with the strategic quality goals of the Office of the Chief Medical Officer, the Population Health Management Services Organization (PHSO) Quality Operations Team supports health care providers across Mass General Brigham to improve quality performance for all patients.

The team includes population health coordinators who provide support to providers at clinical sites, such as conducting patient outreach, to help patients receive timely, evidence-based services.

The PHSO is particularly focused on the following quality areas:

Hypertension blood pressure control
Diabetes blood pressure control
Diabetes HbA1C control
Colorectal cancer screening
Adult and pediatric depression screening and follow-up
Childhood and adolescent immunizations
Childhood and adolescent well-care visits

Chronic kidney disease program

The PHSO Advanced Chronic Kidney Disease (CKD) Program is designed to support patients through the transition from chronic kidney disease to renal failure in a proactive, patient-centered way. Rather than relying on urgent, inpatient dialysis starts, the program focuses on education, home dialysis options, and coordinated outpatient care.

The CKD care team includes an advanced practice provider and dedicated support staff who organize, monitor, and continuously improve the program as needed to best serve the needs of our patients.

Readmission avoidance program

The PHSO Readmission Program is designed to support patients after a hospital stay and reduce the likelihood of readmissions. A centralized care team consisting of a nurse, pharmacist, and coordinator will reach out to patients who are at a higher risk of readmission.

The clinical team conducts patient assessments, reconciles medications to ensure patients are taking them correctly, and helps schedule follow-up appointments with each patient’s primary care provider.

The program uses data to identify patients who would benefit most and uses technology to improve care coordination, clinical efficiency, and patient education. Early results indicate that the program is effectively reducing unnecessary hospital readmissions.

Risk capture program

The Risk Capture Program is the accurate documentation and coding of chronic and complex diagnoses each year in each patient’s medical record. This information generates a risk score, which reflects the expected resource use (claim dollars) for a patient compared to the average.

Health care payers use these risk scores to shape value-based care products that reflect the medical complexity of their members. Most importantly, accurate risk capture helps patients access care and resources to manage their conditions.

The PHSO Risk Capture Team includes nurse coders who conduct chart reviews. When needed, they alert providers to chronic conditions that may not have been reassessed or to possible new diagnoses based on clinical testing. An administrative team supports the program by providing education and tools to help clinicians improve documentation and care coordination.

Behavioral health program

doctor and patient talking while sitting

The PHSO Behavioral Health Program team has two main initiatives to improve the behavioral health care for Mass General Brigham patients. First, through a partnership with Concert Health, we help ensure patients have access to Collaborative Care services. Concert Health employs behavioral health care managers (licensed social workers and behavioral health clinicians) who work with patients using solution-focused techniques to reduce symptoms. Psychiatrists also serve as consultants to the patients’ primary care physicians, offering case reviews, treatment recommendations, and medication guidance.

Second, our Behavioral Health Program team includes social workers and mental health counselors who focus on patients transitioning from emergency departments and inpatient behavioral health units. They conduct post-discharge and level-of-case assessments and implement care plans that connect patients to long-term, community-based treatment and support. The goal is to help patients stabilize, return to their communities, and avoid future hospital readmissions.

Post-acute care management strategy

The Post-Acute Care Management team collaborates with the Mass General Brigham Care Continuum Management team, clinical sites, and a trusted network of post-acute care providers to support seamless transitions and high-quality care after a hospital stay.

Our mission is to ensure the best use of post-acute care, connect patients to the right care at the right time—including at home when possible—optimize referrals for appropriate post-acute placements, manage SNF length of stay, and reduce hospital readmissions.

To support this mission, our transitional care managers closely follow patients receiving care at SNFs within the Mass General Brigham SNF Collaborative, helping manage their stay and ensuring timely follow-up.

We have also recently launched the Mass General Brigham PHSO Home Health Network, which will streamline the home health referral process.

Our team

Leadership

(left to right)

Sharon Wolf, Head of financial planning

Mallika Mendu, MD, MBA, Chief population health officer

Helen Chan, Vice president of clinical product development and strategy

Channah Rubin, Head of clinical and network operations

Jeanine Bulan, MD (not pictured), Associate chief population Health Officer

Central team

The PHSO central team brings together experts in strategy, financial analysis, product and service development, program implementation, and program evaluation. We’re purposely structured to do two things: improve patient care and deliver strong results in our value-based contracts with health care payers.

Our team includes specialized groups that work together to drive progress:

Network and clinical operations: Engages staff, stakeholders, and end users to manage mature solutions, track performance, and drive ongoing improvement. This team works with the Mass General Brigham provider network to support PHSO goals for primary care and integrates PHSO services into primary care practice workflows.
Strategy and new product development: Turns opportunities into action by developing and launching new clinical solutions. These solutions are designed to be patient centered and practical for care teams to use.
Financial strategy: Identifies and quantifies opportunities, then guides teams to meet financial goals that support long-term sustainability and reinvestment in patient care.

Our structure is built on a strong foundation of technology and data. These tools help us make informed decisions, measure impact, and facilitate our work.

Contact us

For more information about Population Health Management and the PHSO, please contact to Keri Sperry or Lusianny Medina.

If you’re interested in learning more about consulting or advisory services offered by the PHSO, please contact Helen Chan.

Education and training

Population Health Management Fellowship

We offer a dynamic one-to-two-year fellowship program designed for board-eligible graduating residents who are interested in advancing their careers in population health and value-based care.

Fellows spend about 30% of their time providing clinical care, with the remainder focused on operational frameworks, programmatic infrastructure, didactic training, and mentorship with population health clinical leaders. The objective is for each fellow to develop the skills to identify, develop, implement, and evaluate population health strategies—within the broader context of value-based care.

Important dates:

Application deadline: September 1, 2025
Decision notification: October 31, 2025
Fellowship begins: July 2026

Application requirements:

Graduation from an ACGME-accredited residency program
Demonstrated interest in population health management and commitment to value-based care
Evidence of leadership potential
A complete application:
- CV
- Two letters of recommendation
- A letter of interest

This fellowship offers the opportunity for enrollment in the Harvard Program in Clinical Effectiveness, a field of study that prepares students to lead clinical research and improve health care delivery systems. The curriculum teaches students to identify the most appropriate, ethical, and cost-effective ways of providing health care through prevention, early detection, cost-effectiveness, and evidence-based care.

Please note: participation in this Harvard program requires a separate application process and applicants must meet the program’s admission criteria.

What you will learn

Upon completion, participants will be able to:

Understand the socioeconomic and political context of population health and value-based care
Describe the financial and operational considerations for an Accountable Care Organization
Match population health strategies to specific patient populations and needs
Analyze program outcomes and make recommendations on program scale and scope
Lead and manage a project team

To apply, please reach out to Keri Sperry

Resident elective rotation

This two- to four-week program provides Mass General Brigham medical residents with an introduction to population health and value-based care. Residents meet with PHSO staff to learn how programs are developed and implemented across Mass General Brigham.

Participants are able to choose a Core Program to immerse themselves in to gain hands-on exposure and foundational knowledge in population health. The rotation provides a deeper understanding of systems-based approaches to program design, operations, and evaluation.