What is the Population Health Cohort?

Collaborative Quality Improvement Opportunity to Improve Population Health

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. Completed applications are due July 31st, 2024. 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

  • 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 $7,000/year.
    • Receive one-on-one support and technical assistance from Well-Ahead staff.
    • Have opportunities to learn from colleagues.
    • Implement/improve standardized processes or tools to improve patient care.

    Members of the Population Health Cohort commit to:

    • Complete an organizational assessment that explores current practices and identifies opportunities.
    • Measure progress toward achieving project goals using the developed Action Plan.
    • Identify staff to participate in activities associated with the Population Health Cohort deliverables.
    • Identify electronic health records (EHR)/data analytic needs and assistance.
    • Produce registries of patients with and/or at risk of hypertension and hyperlipidemia.
    • Participate in Zoom, phone, or in-person trainings and regular technical assistance.
    • Provide regular feedback to help Well-Ahead Louisiana meet identified needs.

    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.

  • Application Considerations

    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 the various 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 Timeline

Application Period ClosesOctober 23, 2020
Site Selection for CohortOctober 30, 2020
Face-to-Face/Virtual Meeting with Selected SitesNovember 2020
Complete Organizational AssessmentNovember 2020
Development of Quality Improvement Work PlanDecember 2020
Quality Improvement Strategy WorkDecember 2020-June 2021
Monthly Meeting and Touch BaseDecember 2020-June 2021
Data ReportingQuarterly; December 2020-June 2021
Dissemination of Tools, Resources and Networking OpportunityOngoing; December 2020-June 2021
Annual Survey and ReportingJune 2021

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