Millennium Population Health Services
Enhanced Patient Services
Graphic courtesy Cerner
Millennium has launched Population Health Services to provide
enhanced patient services to our partners:
- Address gaps in care.
- Assist with meeting quality and performance metrics.
- Help 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 primary care practices.
- Decrease discrepancies found in patient medication lists.
- Identify and address gaps in care for Social Determinants 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.
Meet Millennium’s Population Health Services Team
Millennium’s Population Health Services Team: (standing from left) Ebony White, Community Health Worker; Natalie Shapiro, RN, Nurse Healthcare Coach; Esra Mustafa, PharmD, Care Manager Pharmacist; Tera McIlwain, PharmD, Care Manager Pharmacist; Sandy McDougal, Project Manager; LaTonya Diggs, LMSW, Manager of Social Work. (seated from left) Dr. Kenyani Davis, Millennium Assistant Medical Director; Janet Stoeckl, RN, CCM, Clinical Director; Stuff Cleague, Population Health Services Assistant (Not pictured: Leticia Otis, Community Health Worker)
“Millennium is committed to zeroing in on the key social determinant of health barriers that our Medicaid clients experience (transportation, housing, nutrition, childcare, employment). We are on a mission to help break down these barriers, and in the process, help our partners provide patients the care they need.”
– Michele Mercer, RN, MSHSA,
Chief Clinical Integration Officer
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Millennium’s Asthma and Chronic Obstructive Pulmonary Disease (COPD) Medical Neighborhood program is managed by Janet Stoeckl, Director, Enhanced Patient Services Team, Population Health Services.
The key objectives for the Primary Care program is to improve quality of life by applying patient-centric care and implementing clinical guideline workflow into practices. Strategies employed range from prevention through early warning to high utilization. Improvements anticipated include:
■ Patient experience of care
■ Health of population being cared for with Asthma and COPD
■ Reduction in Inpatient admission, ED visits, and readmissions
■ Provider/Office enhanced satisfaction