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, RN, Population Health Manager/Nurse Healthcare Coach; 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
The mission of the Enhanced Patient Services Team is to work as an extension of Millennium’s network of Primary Care Providers. The program strives to coordinate efforts and identify health care barriers, while at the same time providing hope and making healthcare more about relationship between a care team, patient, and the social aspects of their lives. These systematic changes improve self-management of disease and acceptance of coordinated efforts.
Patients are identified for enrollment based on key criteria established by Millennium’s Clinical leadership 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 in a 90-120 day intensive program. Working one-on-one with the patient and her/his Primary Care Practice, Millennium’s Enhanced Patient Services Team develops a personalized care plan, including specific interventions, for each enrolled patient.
The plan features at least one visit by an RN Healthcare Coach, Community Health Worker or Social Worker and Clinical Pharmacist. During these visits, validated assessment tools are utilized at the initial visit, upon graduation, and 60 – 120 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 Registered Nurse Healthcare Coach works with patients to identify and set goals aimed at improving their health and well-being, and identifying any gaps in care. In doing so, the RN guides the patient care plan and priorities based on the clinical and social determinant of health information collected from each team member.
Millennium’s Clinical Pharmacists work with patients to review medications and answer questions with a goal of improving medication adherence.
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.
For further information contact Janet Stoeckl, RN, CCM, Clinical Director: firstname.lastname@example.org