Disease Management programs at InHouse Physicians are incorporated into our population health management strategy which targets employees with chronic conditions and provides targeted care to produce optimal health outcomes. Our predictive modeling software risk stratifies the population with input from claims data, biometrics, and our EMR. High and moderate risk members receive more intensive management as compared to low risk members.
Patients with specific chronic diseases are invited to enroll in our Patient Centered Medical Home Program. This program coordinates the delivery of evidenced based care to these members in partnership with their primary care and specialty physicians. The goal is to close gaps in care and thus prevent future healthcare claims.
Patients with the following chronic diseases are targeted:
In addition, members with chronic diseases also require assistance in making healthy lifestyle choices. Our health coaching program addresses this need promoting choices that will further decrease their health risks.