What is population health?
Population health aims to improve the health of a group of people. The concept of population health shifts focus from individual care to the broader social, environmental, and behavioral factors that influence health.
State Population Health Accountability Plan (PHAP)
Over the course of the 10-year model, Maryland will make continuous improvements across six key indicators of health. These indicators represent different parts of population health and will help Maryland to assess, over time, how well we are preventing and treating disease in the state. The grid below highlights the initial indicators and the targets for improvement over the next 10 years.
| Domain | Indicator | 2023 Baseline | Target for 2036 (PY10) |
| Population Health | CDC HRQOL-4 Healthy Days Core Module (Self-reported Health Status) | 16.5% with poor or fair health | 16.5% with poor or fair health
|
| Prevention and Wellness | Colorectal Cancer Screening | 49.3% | 54.6% with screening |
| Chronic Conditions | Hemoglobin A1c Control for Patients with Diabetes (>9.0%) | 67.8% | 60.3% with poor control |
| Behavioral Health | Follow-up After Hospitalization for Mental Illness | 64.3% at 30 days;
38.0% at 7 days | 66.8% follow-up at 30 days;
40.5% at 7 days |
| Utilization | Plan All-Cause Unplanned Readmission | O/E= 1.01 | O/E=0.98 |
| “Optional” | Food Insecurity | 16.4% food insecure | 15.0% food insecure |
The
Data Advisory Committee (DAC) met throughout 2025 to select the PHAP indicators and targets. To choose the measures, DAC reviewed: measure definitions and specifications; current baselines and trends over time by subpopulation; relevant background information for each measure; data limitations; and feedback from subject matter experts.
The DAC and the
Maryland Commission on Health Equity (MCHE) will monitor Maryland’s progress on these indicators and provide feedback on implementation. Maryland is required to report progress to CMS every other year.
For more details, visit the Health Indicators Dashboard for regular updates on Maryland’s progress toward reaching these targets: https://health.maryland.gov/dataoffice/mdh-dashboards/Pages/hid.aspx.
Local Population Health Action Plans
Maryland healthcare and public health organizations will collaborate to implement evidence-based strategies to improve health and help the state reach its population health targets. Every Maryland jurisdiction is creating a local action plan specific to local needs and resources, clearly outlining how different community organizations will act to make progress on all six population health measures. This planning process is being led by Local Health Departments in collaboration with community members and partners.
Population Health Improvement Fund (PHIF)
The AHEAD Model also requires Maryland to create the PHIF.
HB1104 established a special, nonlapsing fund to support investments to reach the PHAP targets. In addition to reaching the PHAP targets, PHIF aims to reduce rates of common preventable conditions, address health-related social needs, and/or reduce or eliminate health disparities.
The PHIF will initially invest in Food is Medicine interventions, a set of evidence-based strategies to prevent, manage, and treat chronic conditions through high-quality nutrition. These initiatives support Maryland’s efforts to improve diabetes control, reduce food insecurity and make progress towards meeting the established PHAP targets.
Many states are already implementing Food Is Medicine initiatives through Medicaid. Maryland hospitals, community organizations, insurers, and other state agencies are already focused and making progress on reducing food insecurity and improving diet quality among Marylanders. By funding work in this space, Maryland can assess its impact to date and work towards sustainability.
