Q & A with Population Health

While the population health department at CCI is not new, the team recently underwent a restructuring to increase its impact and service to patients. Since then, they have organized and participated in numerous outreach events to close gaps in patients’ health care. By using data from various sources such as a patient’s Electronic Health Record (EHR), pharmacy records, hospital utilization, and social determinants of health, the team is able to understand patient population trends, characteristics, and barriers. In turn, they use this information to tailor outreach programs that improve health outcomes, reduce the cost of care, and enhance the overall patient experience. Here we talk with the team about their critical work.

WHAT IS POPULATION HEALTH?

“We work with the clinical staff to meet gaps in care. Many patients aren’t aware of care gaps, we bring patients into their care.”

Gilbert Rose Population Health & Patient Panel Coordinator

“The heartbeat or pulse to get patients back to care.”

Candeth Gravette Clinical Care Coordinator

HOW DO YOU GET PATIENTS CONNECTED TO CARE TO CLOSE HEALTH GAPS?

“We have help from everyone. It’s a team effort. CCI patient representatives and medical assistants will call me and say, ‘Hey, I have a patient. Can I give you their information?’”

Lisa Anderson Population Health & Patient Panel Coordinator

“Our community health workers will coordinate rides, appointments, referrals, and make connections outside of CCI to address barriers to care.”

Camesha Thompson Associate Population Health Director

“We use various methods to try and outreach our patients. We call, we text, and we try to engage them while they are at the health center. But we are really excited to start and step outside the clinic and leverage spaces where our community members live, work, and play!”

La Tasha Barnwell Director, Population Health & Quality

For Breast Cancer Awareness Month, the population health team partnered with UnitedHealthcare and Breast Care of Washington Mobile Mammogram Van to provide 3D mammogram services for neighbors with or without insurance outside of CCI’s Greenway health center.