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
- Increase control among adults with known high blood pressure and high blood cholesterol.
- Increase the number of patients identified with previously undiagnosed hypertension.
- Increase the number of adults with hypertension and/or high blood cholesterol who are referred to a healthy behavior support service or lifestyle change program.
Applicants must complete all sections of the application in order to be eligible for selection. Applications are closed for 2023. Check back for 2024 application deadlines.
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 $8,875/year
- Receive one-on-one support from a Well-Ahead Louisiana Nursing Consultant
- Have opportunities to learn from colleagues and leaders in cardiovascular disease prevention and management
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
- Produce registries of patients with hypertension, hyperlipidemia, and diabetes
- 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.
The following variables will be considered when reviewing applications:
- Use of EHRs
- Geographic distribution; we will prioritize Regions 2,3,4,6,7,8, and 9
- 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 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.
Population Health Cohort Spotlights
These clinics, members of our first and second Population Health Cohorts, across rural and underserved areas in Louisiana have been working to implement new quality improvement strategies to improve the population health within their facilities. Population Health Cohort members also have exclusive access to an individualized health improvement portal to monitor and evaluate their clinic data.
Population Health Cohort 2
- Basile Rural Health Clinic
- Woodworth Community Health Center
- South Broad Community Health Center
- Primary Care at the Pythian
- Belle Chasse Community Health Center
- Carlock Family Medical Clinic
- LaSalle Family Medicine Clinic
- Marksville Family Care Center
- Morehouse Community Medical Centers
- Primary Health Service Center
- Opelousas General System
Population Health Cohort 1
- Southside Family Clinic
- Lady of the Sea Medical Clinic, Cut Off
- Lady of the Sea Medical Clinic, Larose
- Avoyelles Hospital
- Louisiana Health Care Practitioners
- North Caddo Medical Center
- Springhill Medical Center Doctors Clinic
- Sabine Medical Center Clinic
- Family Care Clinic
- Nightingail Healthcare Resources
- Total Family Medical
Population Health Cohort Timeline
|Application Period Closes||October 23, 2020|
|Site Selection for Cohort||October 30, 2020|
|Face-to-Face/Virtual Meeting with Selected Sites||November 2020|
|Complete Organizational Assessment||November 2020|
|Development of Quality Improvement Work Plan||December 2020|
|Quality Improvement Strategy Work||December 2020-June 2021|
|Monthly Meeting and Touch Base||December 2020-June 2021|
|Data Reporting||Quarterly; December 2020-June 2021|
|Dissemination of Tools, Resources and Networking Opportunity||Ongoing; December 2020-June 2021|
|Annual Survey and Reporting||June 2021|