State Innovation Model

​Population Health Planning in Maryland



Maryland was one of 21 state-level jurisdictions granted a State Innovation Model (SIM) Design
Award in December 2014 (work completed 2015-2016). Maryland’s State Innovation Model (SIM)
design grant for Public Health Services had three project deliverables: (1) the Population Health
Plan: Planning for Population Health Improvement; (2) Population Health Measures Development;
and (3) Care Plan Exchange. All three deliverables are incorporated into the State Healthcare
System Innovation Plan (SHSIP), which was submitted to the federal Centers for Medicaid and
Medicare Innovation (CMMI) of the Centers for Medicaid and Medicare Services (CMS) on January
13, 2017. Each element provides foundational design work and establishes alignment in the
Department’s efforts to accomplish the goals of the All-Payer Model.
The Population Health components of the report are as follows:
Population Health Improvement Plan: Planning for Population Health Improvement
As the Maryland health care system increasingly migrates toward adopting public health
approaches to meet the performance goals of the All-Payer Model, it requires that population
health improvement focus beyond the clinical space to address all factors that determine health,
the social determinants of health and health equity. The Plan is designed for a breadth of
audiences ranging from Local Health Departments and community-based organizations to state
agencies and hospitals. To this end, the Plan looks to enable improvement in population health
outcomes and health equity by presenting a conceptual framework for identifying priority actions
(interventions, policy, programs, partnerships, etc.). Furthermore, the Plan prompts an ongoing
discussion that looks to consider return on investment and net savings as concepts and,
potentially, as tools that can be mobilized when planning for population health improvement.
Finally, the plan outlines future and continuing work including the following: continued
stakeholder engagement, exploration of sustainable funding mechanisms for population health
improvement, continued alignment with the All-Payer Model, Maryland Comprehensive Primary
Care Model, Dual Eligible Accountable Care Organization project and integration with the
State Health Improvement Process (SHIP).
Population Health Measures Framework
To accomplish the goals of the All-Payer Model and prepare for future data infrastructure and
measure needs, the Department, in collaboration with agency partners, CRISP, and Johns
Hopkins University Bloomberg School of Public Health developed the Population Health
Measures Framework deliverable. Maryland has been working with two broad goals:
  1. Begin to identify and develop measures of population health that can be used to bring accountability to the health systems that further the State’s transition to long-term improved health outcomes, health equity and community level health. The focus is to capture health at the population level.
  2. Update the State’s current set of measures for population health to be both more timely and relevant to the All-Payer Model. This includes expanding on the existing State Health Improvement Process (SHIP).

Care Plan Exchange

The Department engaged with CRISP to work with stakeholders to develop an approach to
enable the aggregation and exchange of care plans across providers who are treating the same
patients, especially during emergency room visits and hospitalizations. Improving the exchange
of care plans will help to support the goal of the SIM Design work to develop a strategy to
integrate care delivery for high-need patients in Maryland including those with multiple chronic
illnesses, high-utilizer populations and individuals dually-eligible for both Medicaid and
Medicare. The report outlines the current state of care plan development in Maryland and the
CRISP-enabled solutions to store and make available care plans across providers who are
treating the same patients.


What does the program do?

  • Design models for sustaining population health in Maryland.
  • Develop data measurements for assessing population health.
  • Study care plan exchanges to address gaps in Health Information Exchange.
  • Identify opportunities for mechanisms to fund population health sustainability.
  • Foster public-private partnerships to improve population health among providers, health systems, local health departments, and community based organizations.
  • Develop health care strategies in coordination with federal and state partners.


Where can I learn more?


Questions or comments may be directed to: Chad Perman, MPP, Director, Health Systems
Transformation,, 410-767-4557.
For our updated contact information, please refer to the toolbar "Popular Links" for the "Staff Directory."
Last updated: 2017 Feb 28