A multi-disciplinary team supports patients with preventive care and complex disease management and assists patients through transitions into and out of the hospital. This team includes population health coordinators, nurse care managers, community health workers, and clinical pharmacists. It focuses on improving the quality of care while directing patients to the right care at the right time and in the appropriate setting.
Population Health Coordinators (PHC) support primary care practices in identifying patients with overdue preventative care gaps, such as immunizations or cancer screenings. The PHC team coordinates with primary care physicians and practices to reach out to these patients and help them set up their needed screenings. The team conducts campaigns to reach selected patient groups through patient portal outreaches and self-scheduling invitations. Thus helping to reduce provider burden.
Complex Nurse Care Coordinators help patients with complex medical and behavioral health conditions to better self-manage their health conditions, coordinate among their physicians, and support self-identified healthcare goals. They help "boost" the patient's knowledge and skills to self-assess, plan, and manage their care journey. Complex Care Coordinators work with patient's primary care physicians to help patients stay as healthy as possible in their home setting and avoid unneeded hospitalizations and Emergency Room visits when possible.
Transitional Care Management Coordinators identify patients at high risk of readmission to one of our hospitals and support post-hospitalization outreach and connection to their primary care physician. These nurses ensure patients understand their hospital discharge instructions and help troubleshoot any problems in the transition to home. They can also connect patients with other population health support team members based on their needs.
Community Health Workers work with the Complex Nurse Care Coordinators for those patients with existing health-related social needs and where additional support in accessing and navigating community or governmental resources is helpful.
Clinical Pharmacists support patients with chronic medical conditions to ensure they understand how to take their medications, support medication simplification where appropriate, and support medication substitutions when cost is a barrier to compliance. They support compliance by ensuring 90-day prescriptions and automated fills to help patients maintain control of their chronic conditions.
Value-based care
YNHH Clinical Affiliates participates in value-based care arrangements with many health plans and government payers. Value-based care leverages innovative technologies and partnerships to support the whole patient's needs, from preventive care to complex cases requiring hospitalization. The design is based on the Accountable Care Organization (ACO) model, a core component of the Affordable Care Act.
Meeting Patient and Family Needs
Patients have options when choosing healthcare providers. YNHH Clinical Affiliates reduces the confusion and difficulty of navigating a complex healthcare landscape. Seamlessly integrating patient communications and medical records, more timely appointments, and a better healthcare experience overall make YNHH Clinical Affiliates' physicians the chosen destination for healthcare needs.
Whether insured by private companies, Medicare, Medicaid, or self-paying, all YNHH Clinical Affiliates members benefit from leading edge technology and clinical support system designed to meet their needs.
Data-driven Care
Using cutting-edge data analytics and predictive modeling, YNNH Clinical Affiliates gives our member physicians an in-depth view of their patient's medical, behavioral, and social needs. Our population health teams design a program of outreach and connections based on analytics to improve and anticipate care needs.
