Population Health

From rhetoric to reality

In the past few years, there‚Äôs been a lot of talk around “population health.” About building a “fee-for-health” model that successfully manages the health and wellness of entire populations. About shifting the focus from sick care to health and prevention. About aligning incentives and improving outcomes.

Until now, it’s been just that — talk.

But that all changed in September 2015. That’s when Ampersand Health opened three CityLife Neighborhood Clinics in Philadelphia — and population health moved from rhetoric to reality.

It all starts in neighborhoods

While there are a number of companies experimenting with the population health concept, Ampersand Health is putting its plan into action, starting with neighborhoods in Philadelphia.

The Ampersand Health model focuses on markets made up of inner city neighborhoods that traditionally lack access to quality, coordinated care — like University City, The Avenue, and Spruce Hill communities. These Philadelphia neighborhoods are also disproportionately populated by Medicare Advantage, Managed Medicaid, and dual eligible members with few physicians serving them.

At Ampersand Health, we know that population health comes alive when members are no longer theoretical or distant — when interaction goes beyond an app, website, or call center. That’s why CityLife clinics are in these prominent neighborhood locations and services are tailored to address the needs of the population.

Market dynamics — access, costs, health system consolidation — have a tremendous impact on successful implementation of solutions for our members and our health plan partners. Geographic, demographic, and socio-economic elements are also critical to defining and addressing health as medical conditions, like diabetes, congestive heart failure, and asthma.

Focusing on the last mile

What makes Ampersand Health’s strategy different from the rest? For one, our solution relies on human relationships — the last mile of population health — to improve health and lower costs of specialty and acute care.

We’ve created environments that enable human interaction. Environments that empower care teams to proactively address social and behavioral determinants of poor health. Clinic environments for implementation of tools, such as data analytics, evidenced-based and personalized medicine, and care coordination.

At Ampersand Health, we’re connecting all the dots, not just some of them.

The trusted family doctor

The Ampersand Health model also uses a traditional yet powerful mechanism — a primary care team as the trusted family doctor — to improve health. Physicians are teamed with behavioral health specialists, care coordinators, and pharmacists, reuniting physical and mental health to enhance the leverage of traditional primary care.

Ampersand Health is able to deliver simple, honest, affordable care with better access, lower utilization, and lower costs while improving health long-term. Hours are flexible. Walk-ins are welcome. Transportation is provided. A member of the care team is available by phone 24/7. The result … health care has become easier and more accessible for the people who need it most.

And since Ampersand Health is not tied to a specific health system or provider, the model is expandable and scalable. What works in Philadelphia can extend to other underserved, expensive urban markets.

The Ampersand Health Model

  • Neighborhood clinics provide simple, affordable, team-based care
  • Care teams include a doctor or nurse practitioner, nurse, clinical assistant, administrative assistant, health guide, medication guide & support team
  • Members have 24/7 access to their care team, plus walk-in care 7 days a week
  • Transportation is provided
  • Located in high-density, inner-city neighborhoods in select markets
  • Designed for Medicare Advantage, Managed Medicaid & dual eligible members

A look at the numbers in Philadelphia County … & how they rank nationally


Medicare Advantage enrollees and 391,742 Medicaid eligibles


Medicare Advantage enrollees per square mile (#6 in U.S.)


annually spent per Medicare enrollee (#6 in U.S.)


emergency room visits per 1,000 (#4 in U.S.)


inpatient admissions per 1,000 (#6 in U.S.)


readmissions rate (#5 in U.S.)

Simple ways to innovate care

Walk into an Ampersand Health clinic and it feels different than your typical primary care office. It’s more relaxed and less clinical. Visits start on time thanks to industrialized, proprietary workflows. And each exam room contains something you don’t typically see in a health care setting … a whiteboard.

Why a whiteboard? Because it allows the care team — doctor, nurse, clinical assistant, health guide, medication guide — to map out a path to better health, together with the member. It’s a simple idea that enables better communication, collaboration, and coordination — three core tenets of the Ampersand Health strategy.

Another simple idea is having food available to members. Medications that must be taken with food are often skipped when the food runs out. A costly ER visit or hospitalization can be avoided with a simple meal from one of our clinics’ free neighborhood pantries.

CityLife is just the beginning

Currently, Ampersand Health’s three CityLife Neighborhood Clinics are up and running in Philadelphia, serving Medicare Advantage enrollees with plans to expand into new markets over the next few years. But Ampersand Health’s vision extends beyond CityLife Neighborhood Clinics to include new primary care brands to serve Managed Medicaid and Subsidized Exchange members.

As with CityLife Neighborhood Clinics, these new models will be tailored to the specific needs of its members and our health plan partners. They will be more episodic, require fewer medical resources and integrate more social and behavioral services to meet the health care needs of low-income adults and children in inner cities.

It’s a durable, long-term vision — one that’s built on a fundamental mission to improve health in underserved urban markets. At Ampersand Health, we are putting all the pieces together to bring true population health from a concept to a reality — the last mile in health care.

Visit the CityLife website.
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