This innovative program is comprised of a team of centrally based Population Health Coordinators (PHCs) who are assigned to support designated Primary Care practices and are expected to function as integral members of both their central team and practice-based teams.
Using population registries and related data, PHCs work with their assigned practice teams to ensure that patients receive recommended condition-specific services. For example, PHCs will: coordinate proactive patient outreach to schedule follow up appointments, screen/monitor patients using questionnaires regarding mental health or other conditions, coach patients as they prepare for cancer screening procedures, and provide reminders about their pre-visit lab tests.
PHCs are also expected to monitor and extract reports from patient registries and share with their designated practices population level data and outcome measures on a regular basis. S/he will support primary care physicians (PCPs) and practices in managing their panel of patients using a registry population management informatics tool. By gathering and organizing patient data, the PHC works to identify patients' unmet needs, engage patients in their own care, gather summary information for treatment interventions, and enhance ongoing communication between the patient and her/his care team.
The goal of the Population Management Program is to facilitate high-value, patient-centered care that improves timely access to and provision of preventive services and chronic disease treatment.
Key Areas of Responsibility:
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