Population Health

Population health is the foundation of Steward Health Care Network’s (SHCN) community-based care model. Our population health strategy is designed to improve outcomes and ensure that our providers have the necessary tools to meet their patients’ health care needs. SHCN provides tools, services and best practices to enable providers to approach care from a population health perspective. In collaboration with providers across the network, SHCN implements patient centered clinical integration initiatives focused on wellness and prevention, chronic disease care management, and high risk populations.

Some of the tools and resources available to providers include:

Quality Team Support

Our team provides SHCN providers with support for implementing best practice solutions to improve quality and care management. In addition, this team offers practice-based education on quality measures, coding and electronic medical records (EMR) optimization support, data collection for reporting, analysis, and improvement planning.

Care Management

Steward’s care management department is staffed with experienced multidisciplinary nurse care managers who work with patients, their doctors and families to develop an individualized plan of care. Care management offers a variety of services, including:

  • A review of health functions, including but not limited to: self-awareness, good judgment, memory loss, nutrition, hearing, falls risk and home safety
  • Level of care evaluation, along with placement needs and advance care planning when needed
  • Education for patient and caregiver on chronic illnesses
  • Medication management and reconciliation in the patient’s home
  • Care coordination during inpatient skilled nursing care

Programs include:

  • Complex and chronic patient management program
  • Honoring patient preferences program
  • Healthy transitions program
  • Readmission prevention program
  • Transition management services
  • Social services program
  • CHF care management program
  • Health and wellness coaching

Clinical Pharmacy Program

Steward Health Care Network employs clinical pharmacists to support clinicians in their efforts to provide high quality, cost-effective care to their patients. The clinical pharmacy program team is involved in developing and implementing programs aimed at improving patient care, meeting quality measures related to pharmaceutical practices, and decreasing pharmacy costs for patients and the network.

The SHCN clinical pharmacists analyze medication use patterns and meet with clinicians, individually or in groups, to provide medication management services, review disease state management topics, evaluate pharmacy performance, and discuss relevant topics related to medication use. The clinical pharmacists are also available for specific drug information questions or consultations for medication management and disease-state issues for specific patients.

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