For Mount Carmel Health Partners, Population Health Management is a holistic, proactive approach to healthcare.
Our Population Health Management program has three complementary goals:
- To decrease unnecessary emergency department visits, inpatient stays and readmissions
- To increase routine health screenings (mammograms, diabetes testing and colonoscopies)
- To improve patient satisfaction
Accomplishing these goals requires solid strategies. Ours involve risk-stratifying the patient population (e.g., identifying with chronic conditions like diabetes, COPC, 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 educations, 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.
Mount Carmel has a proud history of reaching out to those in need, including those who are underserved, so the shift to a population health management vision aligned with our mission and vision. Our focus has changed from caring for one patient at a time to holding ourselves accountable for defined populations of patients throughout the continuum of care.