Premier Health Group Population Management

By Jerry Clark, MD, FACP

Premier Health Group (PHG), the clinically integrated physician health organization (PHO), has been implementing its population health programs. These are focused on three main areas: chronic care management; unplanned care; and hospital transitions. We review all ED visits for appropriateness and identify those at high risk (e.g., those individuals who have some barriers to care that lead them to use the ED when a lower cost, more patient-convenient and lower-risk place of treatment might have been used). Our nurse care advisors may reach out to those at high risk to educate and facilitate solutions to these barriers, such as access to primary care physicians, etc. Likewise, we consider all inpatient admissions as high risk, and those cases get the personal touch of our nursing care advisors to work closely with hospital integrated care teams to be sure that the care plans that are developed are executed after discharge. Those outpatients who are at high risk because of multiple medical problems may be invited to participate with their primary care doctor and our nurse advisors in the PATH (Personalized Approach to Health) program. We facilitate a comprehensive exam by the doctor and work to create a care plan. The nurse advisor meets the patient at that visit and continues to help them navigate the complex medical system, overcome barriers to compliance with treatment, and coach the patient to help them attain better outcomes and better health. Our team of dieticians, social workers, pharmacists, health coaches, and nurses supplement the very busy primary care practice to help their patients – at no additional cost to the patient.

These are some of the ways we are helping improve the health and wellness of the communities that PHG serves.

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