Patient Care Navigation & Population Health
Patient Care Navigation & Population Health
Our Population Health Team offers a coordinated approach that meets patients’ needs, focuses on patient education and engagement, and provides intensive management of patients who are at the highest risk for medical complications.
What We Do
By analyzing patient data and clinical history, our team can standardize high-quality care to patients on a consistent basis and identify what types of services would be most beneficial. Our team has three main goals:
Work directly with patients to improve their health care experience.
Lower health care costs for everyone to ensure quality and accountability.
Increase overall health outcomes for all populations served by Choptank Community Health.
By prioritizing outcomes over the number of visits or the volume of services performed, our Population Health Team offers a coordinated approach that meets patient’s needs, focuses on patient education and engagement, provides intensive management of patients who are at the highest risk for medical complications, and reduces healthcare disparities by identifying patient barriers to care such as lack of transportation or navigating insurance issues.
Who We Serve
Every Choptank Community Health Patient will benefit from a skilled Population Health Management Team, however there are certain groups of patients for whom these services are critical including patients with higher risk factors for negative health outcomes. These patients may need enhanced care coordination services, more frequent follow-up, additional social and community support, or help enrolling in a patient support program.
Even patients at lower risk for negative health outcomes will still benefit from services such as automatic reminders about upcoming screenings, such as a colonoscopy or mammogram, options for telehealth visits instead of missing work to schedule an appointment, or an incentive program that promotes healthy lifestyle habits.
These strategies and preventative services are intended to help maintain each patient’s highest possible health status while avoiding crisis events, reducing preventable hospitalizations, and improving overall quality of life.
Our Population Health Team is composed of highly-trained individuals— a group that includes nurses, care navigators, community health workers, care coordinators, dental case managers, data analysts, and many other experts in the field of healthcare administration.
Care Coordination Nurses review trends in care and assist medical providers and patients in navigating the complex system of health care. This includes hospital and ER follow-up as well as ensuring patients with chronic diseases are provided with support to follow their individualized plan of care.
Dental Case Management is essential to track high risk patients to ensure they have timely access to quality dental care. Our Dental Case Manager contacts patients who have been identified as high risk through our school based program, dental and medical programs to identify any barriers that may exist that would prevent the patient from following through with necessary dental care.
Panel Management is a process to review patient rosters from Managed Care Organizations (MCO) who are due for select services such as well visits, cancer screenings and immunizations. Patients are contacted and scheduled for appointments and coordination with the patients’ MCO ensures patients receive care they need to remain healthy.