Northwestern Medical Center, in St. Albans, Vt., which provides over $129 million in patient care annually, believes the foundation of an effective population health program must be built on collaboration. A few years ago they took the initiative to connect local primary care physicians, skilled nursing facilities, home health agencies, their state HIE, and three different ACOs to establish a Regional Clinical Performance Counsel. This group reviews performance indicators and trends (by ACO, payor, clinic, chronic condition, and other measures) and develops targeted treatment strategies for at-risk populations. They have also played a leadership role in Rise Vermont, a collaborative that promotes primary prevention, healthier lifestyles and lower healthcare costs. The rural healthcare provider is exploring new technologies to manage distinct patient populations, including patient registries, clinical surveillance and longitudinal care plans. These tools allow them to more precisely target their programming for maximum effectiveness, leveraging the partnerships and programs they’ve developed to better manage their patient populations inside the organization and out in their communities of care.
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