Improved Outcomes, Healthier Communities

Core Physicians' efforts in Population Health are focused on improving the overall value of the care that gets delivered.  We work to understand the diverse needs of our patient populations and align the necessary resources to address them for a better health outcome.

Value Based Care
Improving patient outcomes, with exceptional service while reducing the total cost of care trend and improving the sustainability of healthcare services.   
  • Accountable Care: Holding ourselves accountable for providing high quality care
  • Alternative Payment Models: Participating in new models of payer reimbursement that reward not only high quality care but also lowering avoidable high cost of care.
  • Data & Analytics:  The foundation to all that we are able to do is guided by understanding our performance with measurable data and leveraging that data to improve patient outcomes and drive goals setting.

Population Health Management
Population Health Management is the strategy for how we identify, engage and support specific groups of patients who are in need of additional support to achieve better health.
  • Care Coordination:  Core Physicians' team of embedded Primary Care nurses who partner with our more complex patients to support their care needs.
  • Transitions of Care: Core Physicians' nurse driven model focuses on patients transitioning from one setting of care to another, working to ensure needs are met during times of higher risk.
  • Post-Acute Care:  Core Physicians' team partners with our community based healthcare organizations to coordinate and optimize the care our patient receive.
  • Digital Health: Transforming how we connect with their Core Physicians care teams to better meet their needs and further engage them in their care.

Clinical Quality Improvement
By identifying and implementing quality improvement initiatives within Core Physicians' Primary Care offices, and through  our centralized quality team, we aim to achieve annual clinical quality performance targets
  • Addressing Gaps in Care: Identifying and addressing overdue preventive and chronic disease care needs for our patients
  • Quality Metric Performance: Collaborating with our insurance payers to optimize quality of care

Health Equity
Ensuring fair and just opportunity for everyone to attain their highest level of health regardless of race, color, national origin, sexual orientation, gender identity, disability or age.
  • Demographics and Outcomes: Understanding who makes up our community and seeks out our care, to improve how we provide that care to drive positive outcomes.
  • Diversity in Employment & Recruiting: Ensuring our policies, actions and culture are welcoming and supportive of a diverse workforce.
  • Community Partnerships: Community-based organizations are the network that our patients require to achieve better health

Behavioral Health and Substance Use Disorders
Our health system is commited to addressing the complex clinical needs of our community, including mental health.
  • Cross-system Initiative: Working across our affiliate organizations and associated sites of care to improve our competencies and resources to better address the mental health and substance use needs of our community.
  • Embedded Primary Care Model: Core Physicians' model includes Behavioral Health Clinicians within our Primary Care offices for improved hand-offs of care and collaboration with our Primary Care providers and our community based organizations.
  • Trauma Informed Care: An approach to patient care that acknowledges the need to understand a patient’s life experiences in order to deliver effective care.  

Core Physicians' Population Health Leadership Team
  • Darren Guy, DO – Chief Population Health Officer
  • Bobby Kelly, MD, MPH – Medical Director of Quality Improvement and Innovation
  • Linda Kenney-Janosz, MPH – Senior Data Scientist
  • Sarah McGuire, RN, DNP -  Director of Population Health Operations
  • Drew Olick, RN – Program Director of Quality Incentives and Community Integration
  • Kristy Tavitian, RN – Manager of Care Coordination