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MAKING POPULATION HEALTH MANAGEMENT WORK
With Mount Carmel Health Partners ’ strong care management foundation , we ’ ve embraced population health management as a proactive and personalized approach to healthcare .
Our population health management program has three complementary goals : 1 ) to reduce unnecessary cost and utilization , 2 ) to increase routine health screenings ( i . e ., mammograms , diabetes testing , and colonoscopies ), and 3 ) to improve patient satisfaction .
Accomplishing these goals requires solid strategies . Ours involve risk-stratifying the patient population ( e . g ., identifying those with chronic conditions like diabetes , COPD , asthma , and congestive heart failure ), engaging with patients and physicians to manage care in preventive and proactive ways , and teaching patients how to appropriately access medical care and community resources that can help .
Our population health nurses , educators , social workers and other care managers provide inpatient and post-discharge visits , education , care coordination and advocacy , and work with member practices to close gaps in care .
We ’ re developing a number of new and innovative services for our population health management program as well to better connect patients to the care they need , including :
» 24 / 7 Care Line . A phone-in program through which registered nurses offer patients advice , direct them to urgent or emergency care , or dispatch a visit from a home response team .
» ED Navigator . A dedicated physician or advanced care practitioner located in the emergency department to support and guide observation patients to the most appropriate level of care .
» Home Response Team . A team of registered nurses and other care providers that can be quickly dispatched to a patient ’ s home to both triage and provide high-quality , convenient care .
» Enhanced Sub-Acute Care Units . A place at one of our preferred skilled nursing facilities to directly admit patients who may not need to be admitted into the hospital , but have complex care needs .
» Integrated Pharmacist . A dedicated pharmacist to help patients with medication adherence and reconciliation , specialty drug alternatives , and home infusion programs .
» Telemedicine . Allows patients to teleconference with a physician in their home to supplement access to care . » Behavioral Health Social Workers . Provide assessments and treatment of behavioral health issues that can drive patients ’ chronic conditions . » Top 5 % Clinical Committee . An interdisciplinary group of clinicians who focus on developing and executing care plans for the highest risk patients . We believe our commitment to innovative programs like these will ensure better lifelong health for our patients and the entire central Ohio community .
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