Improving Population Health Outreach by Incorporating Team-Based Care & Innovative Virtual Technologies

Problem: Polling over the last two years identified a lack of time, knowledge, and project engagement for population health efforts. 53% of nurses in FY 2022 indicate no time for population health efforts. 43% don’t understand their role in population management, (N-151). 41% of clinical pharmacists in FY 2022 don’t have designated time for population management, and 41% need more population management education, (N-62). 62% of respondents in 2024 don’t conduct population health meetings with their PC team, (N-209). 61% of respondents in 2024 have never led an improvement project (N-188).
Goal: Engage and train primary care champions to increase population health efforts using innovative virtual tools for improved patient outcomes.
Description: This nurse-led project creates population health virtual care champions. The program recruits PC and extended teams for health management training. Teams are taught to review data metrics and utilize virtual tools to improve patient health outcomes.
Objectives: Compare discipline specific roles and operationalize responsibilities by task. Adopt and spread virtual care workflows using innovative tools. Utilize data platforms for identification of patient fallouts to critical screenings and metrics. Design and develop a virtual care action plan and manage the implementation of the plan post-cohort.
Measures of success: Review the impact of the training, including qualitative interviews, polls, and surveys. Identify the number of sites and cohort members trained. Assess the use of virtual tools by cohort members. Analyze HEDIS metrics and health screenings for program effectiveness.
Outcomes: FY24 cohort polls (January – September): 73% of respondents are ready to implement their action plan after the cohort. 86% of respondents are confident as change agents. 95% of respondents identify the cohort program as a needed population health training. 281 staff graduated from the cohort in January to September 2024. The use of virtual tools by members before compared to after completing the cohort (January, February/March, and March/April) is a 160% increase in the use of virtual tools. Members saw a 42% increase in the use of self-reported BP after graduating.
Lessons learned: Provider enrollment in the cohort is critical. Include all graduates in monthly reunions. Provide a national platform to discuss improvement, share best practices.
Next steps: Collaborate with national stakeholders to implement virtual tools and update population health note titles. Develop virtual workflows for population health management. Continue recruitment and training for cohort champions.