Population Health Management in Primary Care Fellowship

Population Health Management is a set of skills to gather and analyze information about groups of patients to design interventions to improve care, including quality, cost and experience of care. For this program we work to develop leaders who are ready to take on the healthcare challenge and make it better. The key skills gained from this fellowship are some of the following:

  • Understand and explain why population management and patient-centered care matter
  • Use data from EHR, claims, third-parties to understand patient needs (use registries, reporting tools)
  • Analyze and improve system processes to enhance access and reduce waste
  • Understand how to compare groups to identify care disparities for vulnerable groups
  • Understand team-based care for enhanced care delivery
  • How to lead change
  • Quality improvement methods

About the Population Health Management Fellowship

Fellows may decide between a one-year fellowship and a two-year training option to pursue their choice of a Master’s in Public Health from the WVU School of Public Health or Master’s in Science. The fellow is expected to qualify for six credit hour per semester tuition waiver, with remaining tuition and fees program paid by the fellowship program.


  • Facilitate transformation of primary care delivery into a patient-centered medical home model to promote compassionate, appropriate and effective patient care.
  • Demonstrate and disseminate knowledge of the established and evolving evidence for population health approaches, and new models of care delivery for enhanced healthcare value
  • Acquire leadership and patient-centered communication skills to work successfully with individual physicians, teams, practices and health related agencies.
  • Demonstrate respect, compassion and responsiveness toward patients and coworkers.
  • Evaluate the quality of care of practice population(s) based on best available scientific evidence and improve care through continuous quality improvement strategies.
  • Demonstrate and promote awareness of the system-based nature of health care quality and the relationship of the practice microsystem to the larger “medical neighborhood.”  


Candidates must have the following qualifications to be considered for this fellowship:

  • Graduate of an accredited residency program in Internal Medicine, Pediatrics, or Family Medicine, with board eligibility or board certification
  • Excellent academic and clinical record

**ECFMG candidates are eligible to apply for the one-year fellowship. The two-year option is not possible due to visa restrictions. Please contact us for more information.

Scholarship Requirements

  • The Fellow will be required to submit a publication and/or present least one presentation (poster or other presentation) related to population health, quality improvement or practice transformation at a national or regional conference.

Participating Departments:

  • Family Medicine located at the Clark K Sleeth Family Medicine Center, University Town Centre –NCQA PCMH Level 3 recognition
  • Internal Medicine Department located at Medical Group Practice, Physician Office Center and University Town Centre—NCQA PCMH Level 3 recognition
  • Pediatrics Department located at the University Town Centre—engaged in active process to become NCQA PCMH recognized