Population health · enterprise view
Population health
Enterprise-wide cohort view across VA, Medicare, and IHS-eligible patients. Risk stratification, condition prevalence, program enrollment, and SDOH burden — sourced from CloudCare RPM, IRIS analytics, and payer attribution files.
VISN 22 + partnered tribes · May 2026
42,184 lives
Attributed across 3 payer streams: 28,418 VA · 11,582 Medicare · 2,184 IHS dual/triple. 8 facilities · 1 model.
Active in CCM/APCM
8,142
19% enrollment
High + V-high risk
10,964
26% of pop · 71% of cost
RPM-monitored
12,418
29% · device + app
Risk strat
Conditions
Enrollment
SDOH
Demographics
Cost & utilization
Cohort · All attributed
Risk stratification · HCC + clinical
Composite score: HCC v28 + RPM signal density + readmit risk + SDOH burden. Top 8% of pyramid drives 49% of total cost.
Very high
HCC ≥ 4.0 · 90d ED
3,374
8.0%
49%
of total cost
High
HCC 2.5–4.0
7,590
18.0%
22%
Medium
HCC 1.0–2.5
16,030
38.0%
19%
Low
HCC 0.5–1.0
11,812
28.0%
8%
Well
HCC < 0.5
3,378
8.0%
2%
Concentration ratio: top 26% of patients drive 71% of cost. CCM/APCM enrollment correlates with 18% lower 12-month cost trajectory in matched cohorts (per IRIS).
Top managed cohorts
DM2 (uncontrolled)
A1c > 8% · 90d
2,418
5.7%
HTN (stage 2)
≥ 140/90 sustained
5,142
12.2%
CKD stages 3–4
eGFR 15–60
1,842
4.4%
CHF (NYHA II–IV)
EF ≤ 40%
912
2.2%
MDD / depression
PHQ-9 ≥ 10 · 6mo
3,184
7.5%
PTSD (lifetime)
F43.1 · documented
2,142
5.1%
SUD (active)
F10–F19 · 12mo
1,418
3.4%
Multi-condition (3+)
overlap cohort · MCPV
8,418
20.0%
Program enrollment funnel · CCM/APCM/BHI · last 12 months
Eligible
28,418
attributed
→
Outreached
22,184
78% of eligible
→
Consented
14,892
67% of outreached
→
Enrolled
10,418
70% of consented
→
Active billable
8,142
78% retention · 12mo
Eligible → Active conversion: 28.6%. Largest drop at outreach → consent (67%); EPO + VIDA scripts under iteration.
Comorbidity overlap · top 5 conditions
% of column patients also having row condition. Read across.
DM2
HTN
CKD
MDD
CHF
DM2
—
68
42
28
38
HTN
82
—
71
32
78
CKD
48
52
—
14
44
MDD
22
24
18
—
28
CHF
21
38
22
12
—
HTN ↔ DM2 and HTN ↔ CHF overlap drives the bulk of MCPV cohort sizing.
SDOH burden · screened patients
PRAPARE-style screening · 18,400 patients screened YTD.
Food insecurity
≥ 1 yes on Hunger Vital Signs
5,888
32%
Transportation barrier
missed appt due to transport
4,416
24%
Housing instability
unstable / homeless / risk
2,576
14%
Social isolation
UCLA-3 ≥ 6
7,728
42%
Financial strain
unable to pay bills past 12mo
6,992
38%
Limited English proficiency
primary lang ≠ English
2,028
11%
Demographics · 42,184 lives
Distribution across age, sex, payer, and facility.
Age 65+
Medicare-eligible
22,778
54%
Age 50–64
pre-Medicare
13,500
32%
Age < 50
young veterans / dependents
5,906
14%
Male
veteran-skewed pop
32,904
78%
Phoenix VAMC
primary facility
26,998
64%
Mesa CBOC
community clinic
7,592
18%
Glendale CBOC
community clinic
5,478
13%