Population Health Services Update: Enhanced Patient Services Moving Forward, Working with Patients and Providers

 

By Peter Ciotta, Communications Director

Millennium’s Enhanced Patient Services initiative has started working with patients and Primary Care Providers. To date, Enhanced Patient Services is working directly with 15 patients and reaching out to an additional 25 patients for program enrollment. The Enhanced Patient Services Team reports to Michele Mercer, Chief Clinical Integration Officer and continues to present the program across Millennium’s network of Primary Care Providers.

Janet Stoeckl
Janet Stoeckl, RN, CCM, Clinical Director

“This Population Health initiative is offering focused, dedicated support to our high-risk Medicaid patients,” explained Janet Stoeckl, RN, CCM, Clinical Director. “By working as an extension of the Primary Care Practice, the Enhanced Patient Services team collaborates to ensure the patients’ care services are connected. We put the patient at the center of all the ways we can work together to help improve his or her health.”

Patients are identified for enrollment based on key criteria established by Millennium’s Data Analytics Team or directly from the Primary Care Practice. Once identified, the Enhanced Patient Services Team works closely with Primary Care Practices to connect with patients and enroll them for services.

After they are enrolled, patients begin a 60-day program, working one-on-one with Millennium’s dedicated Enhanced Patient Services Team and the Primary Care Practice to develop personalized care plans and implement interventions necessary for improving the patient’s health. Each enrolled patient will have at least one visit by an RN Health Coach, Community Health Worker, Social Worker and Clinical Pharmacist. During these visits, validated assessment tools are utilized at the initial visit, upon graduation, and 90 days post services. The use of validated assessments ensures the team is meeting performance metrics and that patients can sustain behavioral and lifestyle changes without direct support from the care team.

Millennium’s Clinical Pharmacists work with patients to review medications, answer questions, and suggest cost-saving alternatives when they exist. They also work closely with the patient’s Primary Care Provider to address any gaps in care. The pharmacists are essential in helping patients set and reach goals around improving blood pressure and blood glucose levels and reducing COPD exacerbations.

Millennium’s Social Worker and Community Health Worker identify Social Determinant of Health needs related to housing, transportation, employment, food, childcare, and other social support services, and connect patients to appropriate resources in the community. In addition, they outreach to patients, promote positive health behaviors, support enrollment in health insurance, connect patients with community-based programs, and provide informal counseling.

Millennium’s Registered Nurse Healthcare Coach works with patients to identify and set goals aimed at improving their health and well-being. In doing so, the RN guides the patient care plan and priorities based on all the clinical and social determent of health information collected from each team member.

“The ultimate goal is to provide the patient with the tools and self-management skills to become an advocate for their own health,” added Janet.

Although the program is growing rapidly, early feedback indicates Millennium’s Enhanced Patient Services team is improving health outcomes for patients and assisting their Primary Care Providers in addressing a broad spectrum of medical, mental health, and social needs.

To date, patients have shared the following:

“I tell everyone about this program!”
“You have helped so much.”
“This was the push I needed to get back on track; I had given up on myself and now we are doing so much better!”
“I like setting goals.”
“I am learning so much!”

Providers have also begun to share positive feedback including:
“Great program!
“Going out in the community is so needed”
“I wish you could see every one of my patients!”

“Millennium Collaborative Care’s Enhanced Patient Services Team listens to our partners and evolves our work given the needs of their practice and patients,” Janet concluded. “We strive to be flexible and meet our partners’ expectations, acting as an extension of the great care they are already providing.”

Share

Add Comment

Your email address will not be published. Required fields are marked *

Join Our Quarterly Newsletter

ECMC logo

The Erie County Medical Center (ECMC) is the lead entity in the Millennium Collaborative Care Performing Provider System.

Millennium Collaborative Care

1461 Kensington Ave
Buffalo, NY, 14215

t:  716-898-4950
www.millenniumcc.org

© Millennium Collaborative Care.