QI Weekly
Asthma Medication Ratio (AMR)
Population Health Team
Why?
- As more of our payer contracts move toward value-based programs, the Population Health team has merged and expanded in order to meet the growing needs. In August 2019, the Family Medicine and MEAC teams were merged to provide a single focus for our value-based programs.
- In addition to the centralized team at the Downtown Center, we also have nurses embedded in the primary care clinics who provide face-to-face care. Some of these case managers are members of the Pop Health team, while others are clinic employees, but all work together on the various programs to improve patient care. Additionally, some of our insurance payers also have employees embedded at the Downtown Center.
- Manage around 60,000 active patients across all specialties and clinics, with particular focus on Primary Care, OB-GYN and Pediatrics.
- Manage 20+ value-based programs, including the UPL, ACO, CPC+, MIPS, TennCare PCMH, and all of the payer-specific programs. Meet monthly with payers.
- Obtain and maintain PCMH certification for our primary care clinics.
- Work with clinics, staff, residents and faculty to implement new workflows and track progress throughout the year.
- Utilize case managers to assist clinics with patient outreach, post-discharge calls, and chronic care management.
- Monaco Briggs, MBA — Director of Quality Improvement and Operational Optimization
- Jennifer Logan, MA — Director of Population Health
- Shana Atkins, MPH — Population Health Program Coordinator
- Vanessa Canter, MBA —Quality Improvement Coordinator
- Tracy Jones, AAS — Lead Data Analyst
- Hannah Vitt, RN, MSN— Data Analyst
- Jan Hubbard, RN — Lead Case Manager — Johnson City Internal Medicine
- Karen Myers, LPN — Case Manager—Kingsport Internal Medicine
- Risa McClain, LPN — Case Manager—Centralized Betty Dellinger, RN — Case Manager, Centralized
- Morgan Tipton, BSW — Care Coordinator—OB-GYN and Pediatrics
- Millie Wykoff, RN — Patient Health Manager, Johnson City Family Medicine
- Maggie Holifield, RN — Patient Health Manager, Kingsport Family Medicine
- Pam Musselwhite, CMA — Patient Health Manager, Bristol Family Medicine
- Freda Campbell, LPN — Case Manager — Pediatrics
- Triston Howell — Student worker
- Heather Click, RN—BCBS embedded case manager
- Sarah Darling, RN—Humana embedded case manager