Population health is Lee House’s initiative to connect our medical community together. To create a healthier Southwest Florida, much of the population, Health values rely on transparency and communication about patient care. The primary pillows of population, Health are access to primary care physicians and Specialists high-risk Care Management, Post Acute transitions accurate, coding of diseases, high value, Network analytics risk, stratification.
And Pharmacy benefits management. So, population health is a department within Lee health. And the reason that is formulated that way is so that we have a contract with multiple different insurance companies with Medicare with Medicaid and that we have a large group of providers and different facilities that are located in our region, which includes Seven, Counties population Health itself is a Process of taking care of patients across the healthcare Continuum, where they come into the hospital, whether they're discharged, whether they're going to in a Skilled Nursing Facility where they're going home with home health and it really connects the patient from the inpatient outpatient and all the different areas so that we can coordinate and help the patient navigate a very complicated Healthcare landscape.
So the value to the patient is, how do we get the patient to get the right Care at the right time at the right place and also at the right cost, but in population health, and when you're talking about value, it's getting the patients, the care, they need at the place where they need it, not where we want them to go, not where we, as Physicians, you know, decide they will go. We help the patients be successful in their own environment.
Population health is an Innovative program that connects the patient's journey across the healthcare, Continuum with warm handoffs, clear Communications, and smooth transitions all with a strong patient focus. This program is leading us into a value-based care model, which is an Innovative program for Southwest Florida at Lee Health. It involves Physicians providers facilities, nurse Navigators behavioral health professionals and Community, organizations. Population Health delivers an exceptional navigational experience across the Continuum of Care through addressing the social determinants of health and removing barriers patients encounter when accessing Healthcare. This work helps patients succeed. In becoming independently knowledgeable, about their medical conditions and healthier at home with a streamlined approach to Patient flow. We can remove unnecessary barriers for patients who are trying to access care to their Physicians providers or health services. This results in improved communication easier access to care and healthier outcomes for our community.
Let's talk about Lee Health's role in population Health, with patient-centric Healthcare and a clinically Integrated Network. At the core of this initiative. Lee health is collaborating with our community to create a strong foundational Network, comprised of high-value, resources and quality focused providers to support all population, Health based initiatives. Utilizing three unique programs in partnership with existing, Lee Health Resources. Lee health is building the framework to support future generations and the commitment to high quality Care, the regional medical and Community Resources through Innovative Health, Best Care collaborative and the Vita Health allows Lee Health to expand our Outreach to patients and offer better support to Physicians and providers.
Innovate US Health is a physician LED locally owned Regional network based in Southwest Florida. The Network's focus is aligning Primary Care Specialists, Health Care Systems Behavioral Health, and other key Community Resources centered around value-based care and focused on the patient. Innovators Health, Embraces, evidence-based, protocols, physician-led decision-making, and longitudinal care advising across the Continuum of Care. The University's health nurse navigation, team aligns with providers, and practices to offer, at-risk patients, a nurse navigator to guide them throughout their entire episode of care outside the hospital. The nurse Navigator provides personalized, care coordination and education connections to Community Resources. Behavioral Health, Resources, home, and follow-up appointment, visits scheduling assistance medication, reconciliation and Specialty. Pharmacy. Assistance, solving dietary.
Carriers Transportation assistance, chronic Care Management and improved communication and collaboration with a healthcare team and their patients. Population, Health investment of on-the-ground nurse navigation. Teams provides patients with greater assistance when transitioning from the acute care setting or skilled nursing facilities back to the community. This allows for a more personalized approach to the Care. Management component, ensuring successful navigation in the ambulatory setting. Finally, Innovative health is invested in technology platforms focused, on high-risk Care Management, through their risk stratification. These Partnerships allow the network to generate data across multiple platforms, to assist, Physicians and providers in identifying. Those patients in most need of nurse navigation, providing visibility for Network performance and data. Transparency with the purpose of developing a high performing high quality Network, delivering care to the patients.
At the place, they need it. Seeing the big picture allows providers to make quality Focus, decisions in the best interest for their patients, ensuring that the patient received the Right Care at the right time. And in the right setting at the appropriate cost. The Vita Health is a Florida. Medicaid managed care plan. Please utilize this URL to learn more about them. Www.vitac.com Best Care Collaborative or BCC is a wholly-owned. Double Care Organization of Lee Health. Best Care. Collaborative consists of primary care, physicians and providers working together to benefit over 19,000 patients. This is accomplished through directly Contracting with Medicare for the southwest Florida area. Physicians and providers are offered the opportunity for shared savings based on performance. Metrics concerning the cost of care for Medicare for several programs in population Health, including CC and the CMS bundle program under Innovative health.
How does population health value behavioral health? For my point of view, Behavioral Health has a huge role and population health is lots of people walking around with depression anxiety, trauma and substance use disorder. And if, when you're talking about taking care of a population, you really have to take care of the whole person, including all the behavioral health conditions that go on either with chronic disease or us as Standalone problems that we have to address the pain.
Impact of looking at behavioral health conditions in the local community. Is that it? It addresses, what? Ails people there are lots of things that people carry around that we haven't been paying a lot of attention to. And so, one of the things that we're looking at now are better ways of both screening, for behavioral health problems, treating them in a multiplicity of settings, like Primary Care, with specialty clinics. So, in addressing that It will more fully address. What goes on in people's lives. The primary care integration project is really important. This is something that I did in Boston many, many years ago, and it has all of the benefits that I've talked about, people will come in. They get screened, we talk to them about, you know, what's bothering them either from an anxiety or depression standpoint if they're struggling with substances, we address that as well and we get the right Care at the right place and at the right cost, what we know is that patients like this sort of I meant, it's very convenient. They don't have to wrestle with transportation problems. And so the patient satisfaction, the patient experience is as good or better than if they were seen in specialty clinics. So that's really important to us. Another thing that we've done in population, health is to create a behavioral health case management program that works in tandem with the nurse Navigator program. So we are now paying very specific attention to the behavioral health problems that are in nurse Navigators are struggling with by integrating Behavioral Health into Primary Care practices. We will meet our patients, mental physical, emotional and Behavioral Health needs in their homes. Provide timely interventions improve patient outcomes and reduce the overall cost of care. With this line of intervention.
We can reduce hospital readmissions and focus on our patients, long-term health. Let's hear one providers perspective on the impact of population Health on his practice as a primary care. Doctor specifically, in Family Medicine, population Health can often seem like kind of just a term that was made up to really describe a large concept that many of us don't understand. And I think what I see in my real practice is the changes that we've been able to make in our area for community. So one of the examples is we have a transportation partnership with one.
Local taxi providers and so really with in population Health, something as simple as how to my patients come and see me for their appointments is a huge need that our community has been asking us to address. And I think we've made some really big steps towards addressing that in the last year or so. And so one of the things I've been able to do is offer last fall, flu vaccines to patients in their house with help of some of our home healthcare providers, and so really trying to meet our patients where they are. Are particularly at home has been something that's been a new offering. I've been able to give to some of my patients who previously would have to come in to the pharmacies or to their doctors offices to get their vaccines.
Patient impact stories are very important. Particularly when we're talking about getting new members, new positions, new providers to be excited about what we're trying to achieve with innovate us. And so, a story comes to mind of a 65 year old female, patient of mine that had quite a complicated medical history. She had a little bit of a difficult living environment at home in that she was wheelchair bound. And there really wasn't a lot of support and the home. Environment was a little bit difficult for her to navigate. And so what I was able to do was By calling our nurse Navigator program, they were able to actually conduct an outside home visit at the patient's home. And so the team was able to get together to do an intake with her and actually identified that she had a supplement as part of her health care that allowed her to transition into an assisted living facility. And so that patient actually, after years of really struggling to be somewhat independent. We were able to happily provide her an option and get her into an assisted living facility where she had a lot.
More freedom to kind of experience life that had offer down here in Florida. And really just have some Independence that she wasn't able to have prior to this. Join us in connecting the medical community to create a healthier, Southwest, Florida.
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