Population Health Management

Our Model Of Care

Whittier is “mid-course” in implementing its Boston Health Equity Program (BHEP), a system of care for people with chronic illnesses that fully integrates innovative community outreach, wellness support and care coordination and explicitly seeks to eliminate health disparities and their associated costs. Specific innovations within this system are:

  • Innovative and culturally appropriate community outreach to increase access to care and early detection of illness with hard-to-reach populations;
  • Primary care that includes visit redesign and a system of off-site Virtual Clinics and that integrates medical care, mental health care and social supports;
  • Medication management to maximize safety for those with multiple complex health issues and to support optimal recovery;
  • Wellness programming that is fully integrated with primary care, tailored to individual needs and buttressed by ongoing support to ensure patient compliance and self-management;
  • Targeted care for cancer patients that fully integrates specialized medical care with wellness, psychosocial support and primary care;
  • Education and assistance in properly utilizing primary care and the WSHC urgent care center to avoid hospital re-admissions and reduce emergency room use.
  • Infrastructure improvements to technology systems to gain efficiency, effectiveness and provide data for continuous quality improvement, including a Personal Health Portal, an enhanced Cancer Registry and on-line transmission and review of Virtual Clinic d
    ata.
  • Establishment of a fitness center to provide an integrative medicine model of care for the whole person.[Read More about BHEP]

Care Management

Care management systems apply science, incentives, and information to improve medical practice and assist patients and families to become engaged in a collaborative process designed to manage medical/social/mental health conditions more effectively.

WSHC care management within the BHEP system is the deliberate integration of patient care activities by all those involved in a patient’s care to facilitate the appropriate delivery of health care services. It refers to activities and interventions that attempt to reduce fragmentation and improve the quality of care, support, referral and transition plan for patients. There are three levels of patient support needed. These levels of support will translate to a care management case rate based on assessment of patient acuity and the level of care needed.

1) Highest risk population management. Clinical care management: Monitoring hospital and ER utilization and hospital discharge reports, medication therapy management. Case managing high risk patients post hospital discharge. Checking in with patients shortly after discharge from ER or hospitals. Care management staffed by RNs.

2) Integrated Clinical Care Management- High risk. Clinical follow-up care: Chronic disease support: education and lifestyle changes. Care coordination staffed by patient navigators.

3) Population health management – Low risk. Care management: Managing e-referral system, assuring transfer of referral information both ways, helping to make appointments, if they have not met their goals. Enrolled patients will be assigned a secure password to the Patient Portal and will be trained in its features.