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.

Mount Carmel Health Partners' Clinically Integrated Network Expansion

Mount Carmel Health Partner's Growth in Covered Lives