We’re changing the way we engage with patients and families to be more proactive and to focus on complete and optimal health of populations.
With a population health management focus, we support the development of new clinical care models and improve existing ones by:
- Leveraging the tools of data, technology, improvement methods and evidence-based best practices to deliver care in a more efficient and effective way.
- Reducing unnecessary variation in order to deliver a consistent patient experience and achieve higher levels of quality and efficiency.
- Engaging patients and families, and the broader community in the design and evaluation of care.
UW Health Population Health Management Programs
Pediatric Complex Care Program
- Program Objective: To provide care coordination and medical co-management in order to optimize health and coordination of care for children with medical complexity who are high utilizers of tertiary care services at American Family Children’s Hospital.
- Program Design: Health care teams including physicians, nurse practitioner, registered nurses and a social worker. Team works with patients and families to coordinate care and communication between all medical providers. Interventions are patient- and family-centered and include inpatient consults, rounding, outpatient enrollment visits, routine follow-up visits, acute care visits, regular telephone contact and attendance at specialty visits when desired and/or appropriate. Enrollment criteria include at least 3 affected organ systems, at least 3 specialists involved in care and high utilization of inpatient and/or outpatient resources.
- Program Contact: Mary Ehlenbach, MD, Medical Director at (608) 265-6920
RN Care Coordination
- Program Objective: To coordinate care of patients with hypertension, type 2 diabetes and/or depression in order to optimize health and improve overall patient experience. The RN CC acts as an extension of the PCP's care plan, working collaboratively with the interdisciplinary health care team to engage patients in successfully self-managing chronic disease.
- Program Design: RN CCs are located within primary care clinics and offer patient- and family-centered care by providing additional attention and support between health care visits. They proactively reach out to patients to address health goals and build confidence in self-managing their chronic conditions. The goal of this UW Health service is to re-engage patients in our primary care settings who have not actively been seeking care, or who have not actively been focusing on managing their chronic diseases.
- Program Contact: Jill Lindwall, Program Manager, at (608) 826-6785 or Jill.Lindwall@uwmf.wisc.edu
- Program Objective: To improve preventive screening and immunization rates for primary care patients.
- Program Design: Centralized medical assistants utilize Health Link reporting tools to identify UW Health primary care patients who are overdue for screening and/or immunization and reach out by a letter, followed by phone call, if needed.