Population Health Management (PHM) is a new approach to the delivery of health care. The strategy behind PHM is to:
- Keep healthy patients healthy through regular checkups and age-appropriate screenings to minimize health risk and decrease the cost of their care in future years
- Closely manage individuals considered “at risk” — those with the most serious health issues — and deliver medical services they need and avoid costly and unnecessary care.
Care Coordination at Springfield Clinic assists with this approach by partnering with providers and patients to overcome barriers and achieve the best possible health outcomes. The Care Coordination team consists of:
- Care Coordinators
- Case Managers
- Patient Care Advocates
Care coordinators and case managers focus on patients who have been recently discharged from the hospital to help them transition from hospital care back to the patient’s primary care provider. They work in the provider’s office as a member of the care team, and help patients for a minimum of 30 days to identify and overcome barriers to their health, and avoid preventable hospital re-admissions.
Patient care advocates reach out to patients by phone to help identify gaps in their care. They schedule patients for age-appropriate screenings, disease specific labs/tests, and perform fall risk and health literacy assessments. They work closely with providers but are not embedded in provider offices.
The goal of the Care Coordination Department is to focus on care delivery to our ACO/MSSP patients and help expand the “Population Health Management” concept to care for all patients aligned with Springfield Clinic.