The Population Health Management teams employ a holistic approach to improving the patient health outcomes at Atrium Health Wake Forest Baptist. They focus on providing various patient population, those in certain geographic areas, or specific diseases or defined characteristics, with care plans that support their unique needs.
The move away from patient fee-for-service to a value-based model has made managing population health a leading priority at Wake Forest Baptist. As we strive for quality of care at less cost, we have invested in quality improvement projects, informed policy development, an aligned health care system and health care providers who care.
What We Do
By combining innovation with care delivery and compassion to transform value-based care delivery and improve population health across the enterprise, we negotiate value-based contracts and alternative payment models to create resources that allow us to collaborate with community, internal and external stakeholders to improve individual and population health.
How We Do It
By following our Core Values, we
- Promote primary care as partnering with the individual to maximize their overall health
- Promote quality and equity of care
- Reduce healthcare costs while improving population health metrics
- Advance and seek innovation and collaboration with our partners
- Drive meaningful change through transforming our care models, scaling and sharing outcomes
Who We Are
Population Health Core Team
The Population Health Administrative team is focused on providing additional resources and expertise to support the full range of services facilitated by the collection Population Health Management team for optimal performance.
Health Navigation Team
A highly collaborative multidisciplinary team that consists of registered nurses, social workers and community health workers who provide holistic care.
Population Health Pharmacy Team
This team is accountable for medication-related strategies designed to optimize patient care and outcomes, improving health and reducing the total cost of care while considering determinants of health.
Clinical Documentation Excellence Team
These are seasoned registered nurses with specialized training and credentials in ambulatory diagnostic coding, focused primarily on risk-adjustment and quality outcomes.
Patient Care Advocacy Team
This team is focused on care gap closure and ensuring that out patients are receiving the appropriate preventive and chronic care.