Issue No. 1 | August 2017
Population Health Bulletin
Toni Modak, RN, has been the Director of Population Health for just over a year and was integral to the development and implementation of the department. Toni came to ColigoCare with 28 years of clinical and leadership experience and has spent the last 10 years collaborating with post-acute providers and improving transitions of care and quality outcomes across the health care continuum.
Through the dedication of Toni and the Population Health team, members of ColigoCare are now able to use the Population Health department as a resource for managing patients with multiple comorbidities and/or those who are considered to be medically high risk.
Some of the resources that are currently available to providers are:
Care transitions coordinators, who identify ColigoCare patients admitted to the hospital, communicate with providers, monitor patients as they are transitioned into post-acute care settings and coordinate community resources to help avoid re-hospitalization and improve patient outcomes.
Population health specialists are a team that monitors quality reports and communicates any gaps in care to the individual practices.
Post-acute care navigators follow patients admitted to skilled nursing facilities to emphasize quality care, provide education and help to determine appropriate discharge planning.
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