Program or Project:
Care Outreach and Education
Percentage of time over term member will spend with this program:
Using population health management software, the member will identify patients due for specific preventive or chronic care services, and develop outreach plans (may include mail, text, patient portal, or telephone calls). Member will provide brief chronic health education for targeted patients who come into the health center for follow up services.
Once fully trained, the care navigator will reach out to an average of 100 patients weekly for care due reminders, with 10 receiving brief chronic health education weekly.
NHC performance measure(s) this activity falls under (if any). :
Access to Care: Self Disease Management; Patient Navigation Services; Health Education