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Population Health Program

The NBN Group’s Population Health Program is designed to achieve the Triple Aim in healthcare. Better patient experience, enhancement of patient health and reduced cost of care. Our team is dedicated to helping insurance companies and employers improve the health of the employees and subscribers they manage.

We use RN Health Coaches, Dietitians, Resource Coordinators and Licensed Clinical Social Workers to support and improve the health of our patients. This team of clinicians ultimately want to encourage and support patients to play a bigger part in their own healthcare and meet their current wellness goals.

“The most powerful medicine is at the end of your fork, not the bottom of your pill bottle. Food is more powerful than anything in your medicine cabinet!”
Mark Hyman M.D.

Program Goals

Our goal is to elevate patient engagement, give patients the tools to help them manage their care and improve their health, and lower the cost of care.

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NBN Population Health Management:

Our RN Health Coaches/Case Managers

To Help Fully Manage a Patient’s Healthcare Our RN Health Coaches/Case Managers address the five major areas of case management :

  • Clinical- assessing a patient’s medical needs based on their diagnoses, medications and medical history.
  • Financial- researching facility costs to help reduce expenses paid by both the patient and their insurance plans.
  • Variance-finding the differences in quality of care between different facilities offering the same services.
  • Quality of Life-assisting patients in raising their quality of life by meeting their health goals.
  • Client Satisfaction-making the patients feel comfortable and knowledgeable about their healthcare.

How the program works:

Enrollment & Assessment

To start, there is a risk stratification health assessment that can be designed to meet the needs of the client to help lower the cost of care. Patients can be identified as a good fit for this program by diagnosis or by usage of the insurance plan. Anyone with Diabetes, COPD, CHF or multiple co-morbidities would be a good candidate. Examination of the number of hospital visits, major surgeries, and visits to the ER would also be good indicators for this program.

Once the participants are enrolled by our nurses, they will work with their nurse to complete a comprehensive health assessment and develop a plan of care together to achieve individualized healthcare goals.

Motivational interviewing is utilized by our RN Health Coaches to help clients set and achieve their health goals.

How the program works:

Ongoing Support

Through ongoing telephone sessions our nurses partner with the patient to:

  • Make Physician appointments
  • Fill and take all medications prescribed by the physician
  • Assist patients to overcome barriers to filling prescriptions
  • Identify small health goals and help patients achieve them in order to meet their long term goals
  • Initiate consultation with a Dietitian to improve patient eating habits
  • Create a realistic walking and/or workout regimen
  • Establish a therapeutic relationship that helps to motivate the patient to want to be healthier
  • Ensure patients are getting well coordinated healthcare and eliminate fragmentation in healthcare teams

For more information contact Kelly Rogers at

 

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