Join the Population Health Cohort
Population Health Cohort: Improving Chronic Disease Management in Louisiana
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 heart 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.
Through the Population Health Cohort, clinical care teams receive hands-on technical assistance from Well-Ahead Louisiana’s Heart Disease Program and Population Health Nurse Consultant to implement quality improvement cycles, connect care teams with necessary resources to close care gaps and enhance patient care, and increase the utilization of electronic health records to monitor health outcomes of the patient populations. Participating clinics also receive funding to support the integration of a centralized data reporting and analytics solution which facilitates care transformation, drives quality improvement, aids in cost reduction, and simplifies mandated reporting.
Population Health Cohort Applications are closed!
Application submissions closed July 31, 2026.
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. Objectives include the following:
- Increase control among adults with known high blood pressure and high blood cholesterol.
- Increase the number of patients identified with previously 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 hypertension and high cholesterol.
- Advance the adoption and use of EHRs to identify, track, and monitor measures for care coordination and care management needs to address clinical 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 care coordination and care management 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. Completed applications are due no later than July 31, 2026. If you have any questions about the application, email at wellahead@la.gov.
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Why Apply?
Providers play a crucial role in making changes to impact population health. Participating in the Population Health Cohort makes those changes accessible and achievable. It connects you to tangible steps for making big changes and a positive impact.
When you participate in the Cohort, you will:
- Contribute to Louisiana’s efforts to improve the health of those at risk for cardiovascular disease.
- Assist in improving your population health management and quality metrics.
- Earn a financial incentive of up to $15,000/year plus possible additional incentives for health information technology.
- Receive one-on-one support from the Well-Ahead Louisiana Heart Disease Team and Nursing Consultant.
- Have additional opportunities to gain assistance by leveraging the Population Health Cohort to gain priority access to the various prevention programs such as: Diabetes Management and Prevention, Tobacco Cessation and Prevention, Community-Based Blood Pressure Monitoring Programs, Louisiana Chronic Disease Collective and the WellSpot Designation Program.
Members of the Population Health Cohort commit to:
- Complete an organizational assessment that explores current practices and identifies opportunities to expand or strengthen current practices.
- Measure progress toward achieving project goals and deliverables determined by Well-Ahead Louisiana.
- Identify an internal project team, including leads and participants.
- Identify EHR/data analytic needs and capabilities.
- Provide required reporting data of health outcomes of patient populations at highest risk of CVD.
- Participate in virtual or in-person trainings and ongoing technical assistance opportunities.
- Participate in Well-Ahead Louisiana’s post-cohort evaluation measures; including surveys and interviews.
Each selected facility will be required to complete a full 1-year initiative. Selected facilities will be required to sign an agreement that will outline the organization’s roles, responsibilities and funding requirements. Funding is contingent upon completion of all roles and responsibilities as outlined in the agreement. If the organization does not meet these requirements, the full award amount will not be dispersed.
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Application Considerations
The following variables will be considered when reviewing applications:
- Use of EHRs
- Geographic distribution
- Patient population size
- Health center capacity to implement and sustain Quality Improvement Strategies
- Current organizational initiatives
What Happens Next?
Upon acceptance, Cohort members will be connected with the Heart Disease Program Manager to begin work to develop an agreement between the health center and Well-Ahead, assess needs and develop their facility’s customized action plan.
The action plan will help clinics implement system-wide protocols for:
- Standardized processes or tools to identify, track and monitor care coordination and care management needs through referrals to patient care resources.
- Standardized processes to implement or enhance team-based care through multidisciplinary care teams.
- Standardized processes to enhance patient navigation and clinical workflows by identifying clinical care gaps and implementing continuous quality improvement.
- Managing patients with hypertension and high blood cholesterol.
The Well-Ahead Louisiana Heart Disease Team and Nursing Consultant will be available throughout your participation in the Cohort. The team will host an initial training, provide support in developing and implementing your action 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 to and connected with the necessary resources to prepare their organizations to be chosen for the next cohort.