Our program models the patient-centered medical home concept to foster a team-based approach and emphasizes prevention, continuity of care and coordination of care, which advocates for, and links patients to, services as necessary across providers and settings. Our population health specialists provide education and care to patients that are diabetics, hypertensive and/or asthmatic, have special health care needs, or chronic care conditions. Our goal as population health specialists is to help patients improve their health by coaching and promoting a positive lifestyle change.
Staff attend specific training on these topics and can provide the education that is needed to make some of these goals achievable. Staff monitor the gaps that are needed for preventive measures and management of diseases and ensure that patients are notified when they are needed to come in for services.