Population Health Cohort

Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group. It is the effort to improve the overall health of a population in a consistent and personalized manner at minimal cost. Population health is more than access to quality healthcare—it is delivering healthcare in a manner that helps people live healthier and happier lives no matter their demographic, genetic, environmental, medical, social, behavioral, or economic circumstances. Chronic diseases place a heavy economic burden on Louisiana, suggesting a need to form a systematic process using actionable strategies to improve the well-being of our residents.

This is where population health management comes in. The Population Health Cohort is an exclusive collaborative quality improvement opportunity which supports the implementation of strategies aimed at improving population health within a primary care setting, with a specific focus on chronic disease related outcomes. It gives Louisiana providers and their facilities the opportunity to have hands-on assistance in implementing evidence-based practices that can improve their quality of care and their patients’ health outcomes. 

The strategies of the population health cohort include specific focus on chronic disease management, such as hypertension, diabetes, and high cholesterol and screening for undiagnosed hypertension and screening, testing and referring for prediabetes. The Cohort provides participating clinics with Practice Coaches and Population Health Registered Nurses to help improve quality improvement cycles, connect with the necessary resources, integrate practices and utilize their electronic health records to monitor health outcomes of their patient populations.

Population Health Cohort Objectives

The goal of the Population Health Cohort is to improve the health of Louisiana residents through the implementation of evidence-based strategies within a primary care setting, with a specific focus on heart disease related outcomes.

• Identify patients with undiagnosed hypertension.
• Advance the use of health information systems that support team-based care to increase control among adults with known high blood pressure and high cholesterol with a focus on health disparities, hypertension, and high cholesterol.
• Advance the adoption and use of EHRs to identify, track, and monitor measures for clinical/social services and support needs to address health care disparities and health outcomes for adults at highest risk of cardiovascular disease (CVD) with a focus on hypertension and high cholesterol.
• Promote the use of standardized processes or tools to identify the social services and support needs of patient populations at highest risk of CVD through multidisciplinary care teams.

Application Information

Applicants must complete all sections of the application in order to be eligible for selection. Selected applicants will be announced on August 13, 2024. If you have any questions about the application, please contact us via email at charmaigne.johnson@la.gov

What Happens Next?

Upon acceptance, Cohort members will be connected with their Practice Coach or Population Health Registered Nurse to begin work to develop an agreement between the health center and Well-Ahead, assess needs and develop their facility’s customized practice coaching plan.

The practice coaching plan will help clinics implement system-wide protocols for:

• Screening and testing for prediabetes and referring them to programs for lifestyle change
• Managing patients suffering from diabetes and referring them to a Diabetes Self-Management Education and Support program
• Identifying patients with undiagnosed hypertension
• Managing patients with hypertension and high blood cholesterol
• Establishing or expanding the system for medication therapy management 
• Connecting patients to community resources to help manage their chronic conditions 

Your Practice Coach or Population Health Registered Nurse will be available throughout your participation in the Cohort. Your coach or registered nurse will host an initial training, provide support in developing and implementing your practice coaching plan, and support in the monitoring of data. You will meet routinely to assess needs and track progress. 

Applicants that are not chosen for the cohort will be referred and connected with the necessary resources to prepare their organizations to be chosen for the next cohort.