Population Health

The Coordinating Center works with hospitals, physician practices and managed care organizations to deliver customized care coordination and coaching models for at risk populations. Our team has significant experience moving individuals from one healthcare setting to another assisting with planning, logistical coordination, advocacy, identification of person goals and motivators, as well as education. Much of our work is focused on the goal of reducing unnecessary health service utilization (emergency room, observation and inpatient), and addressing the social determinants of health. Using evidence-based care interventions we are meeting the goals of the Triple Aim: improving the health of populations, enhancing the experience and outcomes of the individual, and reducing per capita cost of care for the benefit of communities.

Our Team excels at:

  • Serving people in the community who have extraordinary health, social and disability concerns
  • Reducing costs through appropriate planning
  • Avoiding unnecessary hospitalizations and rehospitalizations
  • Sustaining people in their homes
  • Giving people the information and skills they need to actively participate in their care
  • Using innovative technology to improve population health
  • Building strong relationships with the insurer, as well as partnerships with the individual and family caregivers, primary care and specialty physicians.
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