Community Health’s Population Health Program Provides Proactive Health Care

“We want to look at the care of our patients in a proactive way instead of being reactive,” said Community Health Director of Quality Tracy Upton, RN. “Our Population Health program focuses on specific populations and how to create interventions to address gaps in care or missed opportunities.”

Population health is a relatively new term that was developed to focus on the health of a particular population, noting special needs, trending gaps and inequalities in care, and taking into account environmental, economic and social impacts on the health of a population.

In November 2019, Community Health hired its first population health coordinator, Becky Evegan, a registered nurse, to work within the Quality Management team of the health network.

“The way our practices are structured, we didn’t really have people at the offices who did outreach on a consistent basis, having someone on an organizational level helping patients who are behind in services,” Upton said.

The gap in follow-up visits was apparent during the pandemic when a stay-at-home policy was keeping patients from leaving home, even for a visit with their provider. “Our biggest focus now is who did we miss when we were doing Telehealth visits. We are reaching out to the vulnerable population with multiple comorbidities, getting them in for visits,” Upton said.

Evegan’s background as a certified health coach, pediatric nurse and care manager made her a perfect fit for the position, Upton said. “When she’s on the phone with a patient she’s not just a scheduler. She can coach patients as to why it’s important for their follow-up visits and focus on identifying gaps in their care. When did the provider want patient to come in? Are they due for labs?”

In May, Evegan contacted 781 patients and as of the end of June, 375 of those people made appointments to visit a provider. That is a 48% response to her outreach, and an impressive response from patients and an important step in continuity of care.

Before she makes a phone call, Evegan is gathering information about the patient. “I do a thorough chart review,” she said. “Reading the last notes, the conversations the providers have with the patients. The plan is to get into deeper conversations with the patients, coaching them.”

“She is doing risk stratification for the patient,” Upton said, “Have they been in the ER? Are they overdue for labs?”

In December, Upton and Evegan started reaching out to diabetics, some with elevated A1C levels, letting them know that they have tests pending and asking if they can come in for an office visit. “If I see a patient has no-showed for an appointment,” Evegan said, “I’d reach out to their care manager and ask if they can find the reason why this is continually happening.”

Upton said population health helps to identify, connect, and take action. Parents are often thankful for calls about babies who are overdue for immunizations. If a no-show is because a patient has an insurance problem, Evegan asks a Community Health insurance navigator to reach out to the patient.

In addition to personalized phone calls, the Population Health program takes advantage of digital software for sending automated appointment reminders, emailing through Community Health’s Patient Portal as well as sending letters in the mail.

“We are working on changing our culture,” Upton said. “During acute visits, gaps in care aren’t always addressed. Every visit is patient-centered and an opportunity. We are able to identify not just that a patient hasn’t been in, but that they haven’t been in for a certain type of care.”

The Population Health program stems from the work Upton has been doing as Community Health’s Director of Quality. “We are going to be able to better identify services they need. We focus on point of care such as immunizations, checking blood pressure and keeping that under control,” she said. “The provider is going to be the best advocate for the patient, and that’s why it’s important that follow-ups and routine screenings get done.”

The Population Health program provides a proactive approach to understanding the workflow of the health care staff and the way patients react to their provider’s instructions. Leveraging Evegan’s background as a seasoned registered nurse and her experience with families and care management, she has the ability to dig into reasons for the gap in care.

”I’ve been a nurse for 20 years and I’m used to having conversations with parents, patients, care managers and providers,” Evegan said. “I’m hoping to use my health coaching experience to spend more time with patients teaching about their medications and illnesses.”

Population health focuses on identifying populations, measuring the outcome of the outreach and determining gaps in care. “I have the ability to track the outreach to show our providers the benefits of our Population Health program,” Upton said.

All Community Health medical, dental and behavioral health practices are open for office visits as well as Telehealth appointments. The Community Health website and Facebook page have more information about primary care services, a directory of providers and detailed contact information.

Tracy Upton is a registered nurse, a career caregiver and skilled provider who worked in primary care and pediatrics for 17 years. Upton’s experience as a clinician is being applied strategically now in her role as the Director of Quality, looking to make health care at Community Health more effective, more efficient, and more geared toward addressing health issues before they happen.

Becky Evegan, RN, joined Community Health in 2011 and was named population health coordinator in 2019. As a certified health coach and skilled care manager, she’s devoted 20 years of her health care career to primary care with a specialization in pediatrics. Evegan, a Vermont native, is an avid outdoor woman with a love for animals.