By Michele Mercer, RN, MSHA, Chief Clinical Integration Officer

Millennium’s Population Health Services provides care coordination support to our partners.

The Team is led by Dr. Kenyani Davis, Millennium Assistant Medical Director with key team members supporting implementation of the program including Sandy McDougal, Project Manager, Maternal and Child Health, focusing on clinical; and Esra Mustafa, PharmD and Tera McIlwain, PharmD, serving as Care Manager Pharmacists. LaTonya Diggs, LMSW, Behavioral Health Project Manager, leads the oversight and implementation of the Care Coordination Strategy focusing on Social Determinants of Health supported by Ebony Patterson-White. Community Health Worker Coordinator and Nicole Aloisio, Care Coordinator Assistant.

Millennium’s innovative model of community-based care coordination builds on the existing practice within PCMH and the medical home (PCP) model.

The goal is improved population health utilizing the medical neighborhood and coordinating needed health and social services.

It is a collaboration of traditional medical services and community resources aimed to improve the health of individuals, particularly vulnerable populations by alleviating both medical and social barriers to care.

The population health services care coordination support team provides the following value to our partners:

  • Address gaps in care
  • Assist with meeting quality and performance metrics based
  • Helping physicians to work with their patients in attaining disease state goals (e.g. A1c, BP)
  • Improve medication adherence and patient education
  • Improve the medication reconciliation process within the primary care practices
  • Decrease discrepancies found in patient medication lists
  • Identify and address gaps in care for Social Determinates of Health-related concerns
  • Strengthen partnerships with Community Based Service providers
  • Help patients connect to needed community resources
  • Provide partners with the tools and support for their patients to become advocates for their own health

Recent value-add population health service support examples include two pharmacy care coordination cases referred by a community primary care practice. In both cases, the primary care physician requested medication reconciliation assistance for her Medicaid clients who presented with challenging chronic conditions including, lengthy medical histories, recent hospitalizations, and complex medication regimens. The pharmacy care coordinators reviewed the active medication lists, pertinent lab results and checked for drug interactions and duplications. Recommendations were made to the primary care physician who took action with the information.

To access the team’s services, Please contact Michele Mercer at 716-898-4293; mmercer@millenniumcc.org

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