Population Health Patient-Centered Wellness Program

Florida Health Networks offers a Population Health Patient-Centered Wellness Program (PHPCWP) designed to effectively:

  • Reduce unnecessary hospital readmissionspopulation_section
  • Reduce primary admissions for ambulatory-sensitive conditions
  • Reduce emergency department visits for ambulatory-sensitive conditions
  • Decrease medication costs and
  • Produce improvement in HEDIS measures for the population

The Population Health Patient-Centered Wellness Program targets patients with one or more chronic conditions have increased utilization of health services and poor health outcomes. The goal is to enroll them into an intensive health coaching intervention that provides support through a Patient-Centered Medical Home or community physician practice to coordinate their healthcare needs.

FHN supports clinical practices and physician networks by providing innovative population health management solutions to meet the principles of the Patient-Centered Medical Home. The expected outcome is reduced utilization of hospital-based care, improved clinical outcomes, and greater utilization of primary care services. PHPCWP is delivered collaboratively with community-based care coordination, including community health educators and clinical professionals.

FHN’s health information technology solution includes a care management platform using the Johns Hopkins ACG® system to risk stratify the population using a suite of predictive models. These same predictive models provide an objective and statistically sound measure of health improvement over the baseline. The ACG® risk stratification system is fully integrated with FHN’s care management platform and provides population health data to each member of Florida Health Networks team.