For Providers

The Population Health team aims to address care gaps, reduce health disparities, and improve clinical outcomes while delivering exceptional patient-centered, value-based care. Our programs support high-risk, under-served, and poorly resourced patients by providing preventive care, early intervention, and disease and chronic condition management following hospital discharge.  

How Population Health Empowers Your Practice 

Population Health offers a comprehensive approach that strategically complements your practice, leading to benefits for both you and your patients.

Here's how:

• Increased Primary Care Visits: By focusing on preventive care and early intervention, Population Health identifies patients who may benefit from regular checkups or who are high-risk for developing chronic conditions. Our screenings, and care management plans allow us to consistently monitor the patient’s health, which then gives us the opportunity to educate them and provide next steps if intervention is needed.   
  
  When necessary, we encourage patients to schedule an appointment with their primary care doctor. This means more opportunities for preventive care within your practice to address potential issues before they require more intensive interventions.

• Reduced Avoidable Services: Population Health's focus on care coordination, disease management, and remote monitoring can help patients better manage their health conditions and recognize early warning signs. This helps keep your patients healthy and can lead to a decrease in avoidable emergency room visits, admissions and readmissions, allowing you to focus on providing high-quality care to your patients in an outpatient setting. 

What Your Patients Can Expect

• Coordination of Care Including: 
  • Seamless Care Transitions 
  • Virtual Care via Telehealth 
  • Remote Monitoring Services
• Chronic and Complex Disease Management
• Transitional and Post-Acute Care Management 
• Resource Coordination with Community Partners Including:  
  • Transportation
  • Food
  • Housing 
  • Utilities

Criteria for Patient Enrollment

To qualify for enrollment in Population Health, your patient must meet at least one of the following criteria: 

• Chronic Co-Morbidity 
• Complex Needs & Demonstrated Non-Compliance 
• Socio-Economic Challenges Impacting Care & Outcomes