The Population Health Coordinator (PHC) is an integral member of the Health Center’s Population Health Team and supports the Health Center and its patients to achieve enhanced clinical quality outcomes through quality improvement and intradepartmental coordination. The PHC will accomplish this through updating the electronic health record (EHR) with quality data, performing EHR chart review, creating and utilizing patient registries, tracking patients to ensure test and appointment completion, and outreaching to patients. The PHC plays a key role in the Health Center’s Quality Contract and practice improvement initiatives by working closely and routinely collaborating with Population Health team members, Medical Assistants (MAs), Nurses, Providers, operations staff, as well as, external practices, in order to track care and maintain accurate data in the EHR."
1. Entry of Quality Data into the EHR
Collect paper external test reports and receive electronic messages about external test results from health center providers.
Enter data from external test reports into the EHR in appropriate discreet EHR fields. Examples include and are not limited to colonoscopies, diabetic retinal exams, mammograms, and external lab results (HbA1c, LDL, FIT test, PAP smears/HPV testing).
2. Patient Outreach
- Contact patients via reminder letter, telephone call, or MyChart message to schedule appointments and remind patients about overdue care, including procedures, lab tests, and appointments related to quality metrics.
- Utilize motivational interviewing skills as necessary to appropriately engage patients, directing and receiving support from clinical care team(s) when necessary
- Document outreach and other notes in EHR and other databases to document outreach and outcomes for quality contracts and to communicate to clinical and ancillary teams information about care that is due for individual patients.
- Identify best practices for effective outreach and provide recommendations to pertinent staff accordingly.
3. EHR Chart Review
- Perform EHR chart review for EHR based quality measures and enter into excel spreadsheets as required for ACO and other clinical quality measures (CQM
Patient Registry Management
- Create chronic disease and preventative care patient registries from EHR and other population health software.
- Distribute registries to clinical leads (medical assistant, nurse) within the primary care teams and collect registries to support appropriate tracking and monitoring of patients.
5. Track patients to ensure test and appointment completion for chronic disease management and preventative care
- Utilize registries and excel spreadsheets to track patients.
- Repeat outreach in accordance with patient risk, anticipated patient compliance, etc.
- Inform primary care provider in EHR when outreach has been unsuccessful.
6. Outreach and track abnormal results or high risk conditions
- Utilize registries and excel spreadsheets to track patients with abnormal test results.
- Repeat outreach and track results in accordance with quality contract and Health Center recommendations.
- Inform primary care provider in EHR when tracking has been unsuccessful.
7. Close the loop on referrals related to quality metrics.
- Verify completion of appointment.
- Follow-up if care is not completed.
- Reassign patients when a provider leaves or joins the practice.
- Identify patients who are not assigned to an active PCP and empanel within EHR.
- Provide ad-hoc support with maintaining patient panels for primary care departments.
9. Participate in care team meetings and improvement initiatives
- Attend all assigned Primary Care team meetings.
- Update care teams on population health and performance improvement initiatives.
- Model professionalism and high quality customer service.
- Interface directly with Provider, Nurses and MA’s from assigned teams to identify patients for outreach.
- Work with Population Health Team and Codman’s clinical and operations leaders to codify workflows, disseminate information, and support trainings regarding registries, MyChart, and other population health and practice improvement initiatives.
- Serve as a Subject Matter Expert for the Population Health team (including team interns); providing training to team members when appropriate.
- Serve as a representative for the Health Center in relevant external workgroups.
10. Team-Based Care and other group trainings
- Assist the Population Health Team in planning Team-Based Care and other trainings
- During the meeting, complete tasks as assigned.
- Assist Population Health Team to complete Team-Based Care follow up tasks; including the set-up, implementation, and analysis of new workflows when needed.
11. Other duties as assigned
