The goal of the population health program is to engage individuals in their own health care. Our program elevates the health of the populations, and lowers the cost of care. We employ RN Health Coaches/Case Managers to address the five areas of population health:
- Clinical - assessing a patient's medical needs based on their diagnosis, medication regime, and medical history.
- Financial - researching facility costs to assist in reducing expenses paid by both the patient and their insurance plans.
- Variance - finding the difference in quality of care between different facilities offering the same services.
- Quality of Life - assisting patients in raising their quality of life by meeting their health goals.
- Client Satisfaction - making the patients feel comfortable and knowledgeable about their healthcare.
Getting Started
We employ a risk stratification health assessment that can be designed to meet the needs of the client to help lower the cost of care. Patients can be identified as a good fit for this program by diagnosis or by high utilization of their insurance plan. Anyone with diabetes, COPD, or multiple comorbidities would be a good candidate. Examination of the number of hospital admissions, major surgeries, and visits to the ER would also be good indicators for this program.
Once you are enrolled in our program, our RN Health Coach will work with you to complete a comprehensive health assessment and develop a plan of care together to achieve individualized health care goals. Motivational interviewing is utilized by our RN Health Coaches to assist clients to MEET their goals.
Ongoing Support
Through telephone sessions our nurses partner with you to:
- Make physician appointments
- Fill and take all medications prescribed by the physician
- Assist in overcoming the barriers to filling prescriptions
- Identify small health goals in order to meet their long- term goals
- Initiate consultation with a dietician to improve patient eating habits Create a realistic walking or workout regimen
- Establish a therapeutic relationship that helps to motivate patients to want to be healthier.
- Ensure that patients are getting well-coordinated health care and eliminate fragmentation in healthcare teams
Components of the Program
- Closely monitor transition from hospital to home
- Employment of evidenced based interventions to reduce the risk of re-hospitalizations
- Medication therapy management in conjunction with community pharmacies
- Chronic disease case management
- RN Health coaching
- Dietician involvement
- Social Worker telephonic outreach to stabilize mental health challenges
Please contact us to learn about current employment openings.