As a part of our Clinically Integrated Network, you have access to a full Population Health Team. These team members are all local to our area, so they bring local solutions to local problems. Each office is assigned their own team, so they know who to turn to for assistance, advice, or questions. The members of the team consist of an Analyst, Clinical Pharmacist, Population Health Advisor, RN Care Manager, and Strategic Operations Manager.
Krista is responsible for the reporting aspect of the network. She takes the reports from the payers and configures them into useable, actionable data. She prepares performance packages for our Care Model Committee practice reviews. Krista is your go-to if you are looking for any specific reports or have any questions about reports.
Jessica and Chelsea are responsible for all things medication related but can also be useful in other ways. With an emphasis on medication metrics, including adherence and ensuring patients are on the appropriate medications, they can assist patients if there are barriers such as cost. Jessica is also a Certified Diabetes Care and Education Specialist and can help with educating patients. The clinical pharmacists can also help with direct patient care in the case of annual wellness visits.
Carly, Beth, and Amy are an invaluable asset to your team. As PHAs, they can help identify office process breakdowns and assist in enacting a plan to fix these. They are a wealth of knowledge when it comes to payor specific questions. The PHAs can scour charts for open gaps, outreach to obtain gaps, and even submit these gaps to the payor. The PHAs can take it a step further and outreach patients with reminders of their annual wellness visit and open wellness screenings. Furthermore, the PHAs regularly communicate hospital discharges to ensure timely follow-up care for the patients.
Sonya, Jo, Keshia, and Kayla are responsible for all things clinical. RN Care Managers identify high-risk, high-cost, high-utilizer patients, and do what they can to assist that patient. They identify and touch base with recently discharged patients to ensure their needs are met and they understand their discharge. This also helps facilitate timely follow-up with their PCP. The RN Care Managers are also responsible for educating patients on their diagnoses, medications, treatment plans, and symptom management. The RN Care Managers identify and mitigate SDOH barriers such as transportation or health care costs. The nurses take referrals from PCP offices on any patient that just needs a little more help. Two more vital roles are connecting patients to community and payor resources and assisting with short-term or long-term placement.
Kaitlyn works closely with the Executive Director to strategize on how to improve the network. Kaitlyn has a vast knowledge of every program, each metric, and what they all entail. Yearly, Kaitlyn develops a “cheat sheet” for all the offices to use as a guide. She is the point of contact for specific payor metric questions as well as database issues or concerns. Furthermore, Kaitlyn is versed in the IT side of the network. She runs the IT Steering Committee as well as the sub-committee work group. Kaitlyn has been instrumental in working with the different payers to integrate into the various EMRs in the network.