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Population Health Management
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Drexel's Population Health Management (PHM) Department is a team whose primary mission is to research and redesign clinical care that is patient centered and focuses on the whole person. We utilize an interdisciplinary, data-driven approach to develop, implement and manage a system-wide, value-based population health strategy. The department strives to improve patient outcomes, enhance the patient experience and right-size overall health care costs. We collaborate with faculty across Drexel University to identify and test impactful interventions.

Drexel's PHM Department embeds a clinical innovation team that tests novel approaches to patient-centered care. This intradisciplinary team is comprised of health educators, registered nurses and social workers.

PHM offers a unique academic experience for undergraduate and graduate students, as they have the opportunity to work on one of our many initiatives alongside staff with expertise in population health and practice transformation.

Population Health Management Team

Leadership

Nancy Hansen Porter, MPH, BSN, RN
AVP, Population Health Management

Katie Finlay, MPH, PMP
Director, Population Health Management

Principles of Drexel Population Health Management

  • Adopt a population health approach and reduce health inequities
  • Prioritize health promotion and illness prevention
  • Achieve person-centered care; optimize self-management
  • Facilitate coordinated and integrated multidisciplinary care across services and settings
  • Provide the most effective and efficient care
  • Achieve a significant and sustainable change
  • Evaluate progress

Objectives of Drexel Population Health Management

  • Prevent/delay the onset of chronic disease for individuals and populations
  • Reduce the progression and complications of chronic disease
  • Reduce avoidable hospital admissions
  • Implement evidence-based care in the prevention, detection and management of chronic disease
  • Enhance the capacity of the workforce to meet population demand for chronic disease prevention and care

Programs led by Population Health Management

Patient-Centered Medical Home (PCMH)

Patient-Centered Medical Home (PCMH) is a care delivery model in which team-based care models are adopted to deliver accessible, high-quality and comprehensive coordinated care. Practices recognized by the National Committee of Quality Assurance (NCQA) meet over 100 patient safety and quality metrics.

Comprehensive Primary Care Plus (CPC+)

Comprehensive Primary Care Plus (CPC+) ia an advanced, primary care medical home care delivery model that aims to strengthen primary care through payment reform and care delivery transformation.

Payer Value Based / Quality Enhancement Programs

Payer Value Based / Quality Enhancement Programs are incentive-based programs in which practice performance is compared to annually established benchmarks.

Accountable Care Organization

The Accountable Care Organization ia a core component of the Affordable Care Act and a framework to deliver value-based care. Our shared savings ACO agreement is with a commercial payer, a hospital partner and our ambulatory medical practices. Shared savings are calculated against performance standards which are updated annually.

Patient Family Advisory Councils (PFAC's)

Patient Family Advisory Councils (PFAC's) are established councils that meet regularly and are comprised of patient and family members, providers, and office staff. PFAC members collaborate to identify opportunities to improve patient care and the patient experience.

Philly 1817 Grant

The Philly 1817 Grant is awarded to the Philadelphia Department of Public Health (PDPH) by the CDC to explore “Innovative State and Local Public Health Strategies to Prevent and Manage Heart Disease.” Drexel is one of three large health systems participating, and the focus is to explore innovative strategies for CVD prevention and management at the Family Medicine practices.

New Patient Concierge

New Patient Concierge is an innovative program that aims to provide personal, high quality interactions with new patients prior to their first appointment in our primary care clinics. Patients are connected to a New Patient Coordinator who screens for social determinants of health and obtain a comprehensive medical history prior to their first visit.

Integrated Behavioral Health

Integrated Behavioral Health aims to seamlessly integrate innovative, evidenced-based, behavioral health program models into primary care. Referral and counseling services may be delivered face-to-face, telephonically or a combination of both delivery modalities.

Disease Management

Disease Management services are provided by registered nurses and outreach coordinators. This program is designed to assist patients by developing the knowledge, skills and attitudes required to manage their condition(s) and keep themselves healthy when they are at home and at work. Conditions eligible for this service include (but not limited to) asthma, CHF, COPD, diabetes, hypertension and prediabetes.

Transitional Care Management

Transitional Care Management services are provided to patients who were recently seen in the emergency room or admitted to the hospital. Included in this service is the review of discharge instructions, medication reconciliation, connection to community resources and assistance with appointment scheduling.

 
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