How to Create and Track Patient Cohorts using Glooko's Population Health – Glooko Support | Help Center

Overview

Glooko Population Health is a population analytics tool where clinics can harness Beyond A1c metrics from their patient population to identify and target at-risk patients with timely care and interventions. This is achieved by allowing clinics to run custom data queries across their entire patient population.

Glooko's Population Health module can be used to cohort certain segments of your patient population based on a combination of patient demographics and/or different diabetes metrics.

Once a cohort is established, Glooko will automatically scan your patient population once a day to check for patients who meet the cohort's criteria.

If a patient meets the cohort's criteria, they will then be assigned a corresponding label, or Flag, that is used to identify applicable patients in the patient list.

Cohorts: A segment of your patient population, based on the defined cohort filters
Flags: Labels that appear on the patient list next to patients who meet the criteria for a given cohort

Accessing Population Health

To access Population Health:

Login to your Provider account at my.glooko.com
Select the circle with the account initials in the top right
Select Population Health

Out-of-the-Box Cohorts

By default, Glooko has five different patient cohorts that are established by default and run automatically:

The settings for these default flags may be adjusted at either the individual patient level or at the population level.

To adjust at the Population level:

Select the circle with the account initials in the top right
Select Settings
Scroll to Data Settings
Adjust the values listed under Population Flag Settings
Select Save at the bottom of the Data Settings section to adjust the flag thresholds for your entire patient population

To adjust at the Individual Level

To change the default flag thresholds for a single patient:

Open the patient by either searching in the search bar or selecting from the Patient List
Select Profile next to their name
Scroll to Data Settings
Adjust the values listed under Population Flag Settings
Select Save at the bottom of the Data Settings section to adjust the flag thresholds for that individual only

Creating Custom Cohorts

In addition to the default Flags provided by Glooko, Population Health also enables you to create your own custom cohorts based on the needs of your clinic. To do this, you will:

Set the parameters from your custom cohort
Save and set a name for the newly created cohort

An example cohort would be: Type 1 patients with <50% time in range.

You may then name this cohort T1_Under_50%, which would then show up as a Flag in the patient list. Any patient who meets this criteria would then have this label by their name.

Identifying At-Risk Patients

The available metrics for identifying At-Risk patients are:

1. Beyond A1c (Find patients who have greater than X, less than X, or in between X & Y values for):

Average Blood Glucose
(e.g. patients with average BG >70mg/dL)
Above/Below/In Range
(e.g. patients who have 15% of readings <54mg/dL, 20% of readings >250mg/dL)
Absolute Glucose Level
(e.g. patients who have had at least 1 reading above 500 mg/dL
Check Rate
(e.g. patients who check in between 2-4 times per day)
CGM Time Active
(e.g. patients who wear CGM >50% of the time)

2. Demographics

Diabetes Type
Age

3. Additional Filter Options:

Uses Glooko outside of clinic
- If unchecked, returns all patients (both in-clinic and at-home users)
- If checked, only patients who have synced their devices at home (via Mobile app or Glooko Uploader) are returned
Uses Insulin Pump
Last Clinic Visit Date

Saving Cohorts and Creating Risk Flags

By creating different cohorts, clinics also have the ability to create their own custom flags. These flags will update once a day and appear on the Population Tracker (aka your Patient List), making it possible to risk-stratify the patients based on these flags. In addition to the custom flags, there are also a set of existing Glooko-defined flags available, e.g. Hypo Risk, Hyper Risk, Dropout Risk, Marked High and Marked Low.

To learn more about the Glooko-defined flags and learn how to create custom cohorts, please see Population Health: Custom Cohorts.

Note: The option to export a CSV of the patients in the cohort also exists once the cohort is created.

Pre/Post Outcomes

The Population Health platform also allows clinics to access aggregate before and after outcomes (such as average glucose) for their patient population via the Pre/Post tab. For example, pre/post: Started on Glooko or pre/post: Last Clinic Visit.