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

• Increase control among adults with known high blood pressure and high blood cholesterol.
• Increase the number of patients identified with previously undiagnosed hypertension.
• Decrease the number of adults with diabetes with a hemoglobin A1C>9.
• Increase the number of adults with prediabetes enrolled in a lifestyle change program who have achieved a 5% -7% weight loss.
• Increase the number of adults with hypertension, high blood cholesterol and/or diabetes, who are referred to a healthy behavior support service or lifestyle change program.

Application Information

Applications are closed for 2020! Applications will not be accepted subsequent to the application period.

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.