Implementation of a Population Health Chronic Disease Management Program

8 practices received the support of central population health coordinators (PHCs). PHCs utilized a population health management (PHM) information technology (IT) tool and performed administrative tasks including appointment scheduling, ordering overdue laboratory testing, chart reviews, and obtaining outside tests/labs. In addition, PHCs regularly met with physicians to review those patients who required clinical intervention to develop an action plan. The network did not have sufficient resources to implement a PHC in all of the 18 network practices. So PHCs were allocated by responses from the practice leader, baseline quality scores, size of the practice, nature of the practice (health center vs not), and location of the practice. These decisions were made in a way that sought to equitably distribute available PHC resources within the practice network as a way to get network buy-in and maximize the impact of the program, both for practices with and without PHCs.

Ten practices without PHC support were provided training on how to use the PHM IT tool. The staff in these practices remained primarily responsible for managing administrative tasks.