Population Health Services
To improve the quality of care provided to our patients, UNC Population Health Services delivers clinical and support services through embedded and centralized teams. Our clinical teams provide case management, care coordination, transitions of care, advance care planning, wellness visits, dietary services, disease management, and behavioral health services. Our support services team facilitates patient care gap closure and brings efficiencies to the Health Care System through patient outreach, strategic scheduling, health maintenance records requests, risk adjustment, payer contracts management, chart abstraction, and Epic@UNC Go-Live support.
What We Do
Embedded Care Team
Advance Care Planning (ACP)
Embedded case managers can conduct ACP during an AWV. ACP allows the patient to pro-actively make decisions for their health care.
Annual Wellness Visits (AWV)
Embedded case managers can perform AWVs during a shared visit with the physician or as a standalone visit. AWV’s focus on prevention, screening, immunizations, general well-being of the patient, and patient goal-setting, while helping them set self-management goals. PHS increases AWV utilization via strategic scheduling.
Licensed Clinical Social Workers (LCSW) provide evidence-based behavioral health services through 5-12 sessions focusing on: short-term counseling and interventions, helping the patient identify and work on personal change goals, and providing goal-focused activities to work on between sessions. LCSW’s can also conduct AWV, ACP, and care coordination.
Care coordination is a specialized service provided by Case Managers that identifies barriers to care and links patients to appropriate resources.
Embedded registered dietitians (RD) can provide the following services, one-on-one or in group settings: medical nutrition therapy, intensive behavioral therapy, grocery store tours, and diabetes management group education classes. The RD team has performed over 10,000 visits, touching more than 5,000 patients for nutritional services.
Embedded case managers provide disease management services through a combination of enhanced screening, patient education, and care coordination.
Personal Health Advocate
The UNC Personal Health Advocate Program is a benefit that provides support and management of health care needs for eligible value care participants. Members can receive access to their own personal health advocate team of trained nurses, pharmacists, dietitians, social workers, and care coordinators to assist them with their care needs and help them understand and manage their medications. The PHA team has served over 2,500 patients since January 2016.
Transitions of Care
Transitions Coordinators provide helpful coaching, education, and resources to patients recently released from the emergency room or following a hospital encounter. Transitions Coordinators can assist with scheduling follow-up appointments with patient’s primary care provider or referrals to specialists or other services as needed. Transitions Coordinators currently touch over 1,000 recently discharged patients a week with a goal of preventing readmission. Services are provided to all patients of UNCPN practices and value care contracts.
Anti-Coagulation Clinic Support
In-clinic monitoring of blood coagulation factors with a remote pharmacist. Our team monitors drug dosage, clotting factors, and screens for potential diseases for patient with blood clotting disorders.
Care Gap Closure
PHS reviews open Health Maintenance gaps to support provider compensation metrics, PCIC and quality reporting programs. Semi-annual review of open Health Maintenance gaps to support provider compensation metrics, PCIC, and quality reporting programs. A comprehensive review of Health Maintenance gaps is completed for each new PCIC practice.
PHS can perform legacy full chart abstractions that include demographics, medications, allergies, histories, last progress note, and scheduling appointments, and enter the data into Epic@UNC prior to a practice Go-Live. PHS then provides Epic@UNC at-the-elbow support during the first week of Epic Go-Live to assist clinic staff with the check in/check out process, clinical work flow, chart abstraction, and scanning.
Health Maintenance Records Request
The Health Maintenance Records Request is a centralized, more efficient way to close health maintenance care gaps. Members of the practice care team place an order in Epic to the population health support specialists who contacts external facilities to abstract the report into the patient chart and close the care gap.
PHS facilitates tailored, direct patient outreach for more than 100,000 My UNC Chart messages and letters annually. This outreach informs patients of overdue preventive health screenings and immunizations. It also assists our care teams in ensuring patients remain updated on the status of their preventive care, empowering them to make the best decisions regarding their health.
PHS works on behalf of practices to obtain prior authorizations for behavioral health and nutritional services freeing up provider and practice staff time.
PHS works with practices and case managers to assist with schedule optimization, specifically scheduling AWVs, prioritizing high impact populations such as high risk patients, high HCC/RAF gaps, open Health Maintenance gaps, and value-contract patients. Strategic Scheduling also performs care gap closure.
PHS offers remote retinal imaging for diabetic patients at clinics with access to a retinal camera. This service allows for a brief screen of diabetic patients who have not had an eye exam in the last year for sight-threatening diabetic retinopathy.