Population Health Management - InHouse Physicians

Population Health Management


Addressing “Gaps In Care” With Population Health Management

In the United States, a majority of patients are not getting the care they need. This gap between nationally-recognized, evidenced-based medicine guidelines and the care patients are currently receiving is termed “gaps in care.” These gaps lead to poor patient outcomes and much higher costs for employers who are self-insured.

InHouse Physicians nurse case managers aggressively target high risk patients and partner with your employee’s primary and specialty care physicians to coordinate the delivery of care, and provide patients with the necessary tools to close gaps in care. 

Targeted Enrollment Programs To Boost Positive Health Outcomes

InHouse Physicians conducts a comprehensive outreach program to connect with these patients and encourages enrollment in targeted programs to close gaps in care and modify their lifestyle choices.

InHouse Physicians has a robust strategy in identifying and engaging your population by:

  • Using predictive modeling software and electronic medical records to identify high-risk patients
  • Implementing automated outreach systems that communicates with patients
  • Connecting the patient to the Medical Home Model personnel that address healthy behavioral choices (health coaching) as well as psychosocial obstacles and issues with compliance
  • Streamline care coordination with all providers delivering care to the patient
  • Continuous measuring and reporting to track performance