Physician Directory
Clinic Directory
Contact usOur Patient’s Medical Home (PMH) team can help identify patients who may benefit from proactive screening or chronic disease management. Proactive outreach enables earlier detection of patient health concerns and connects them with the care they need.
How it works
Health Information Coordinators review EMR data to distinguish patient groups and set a specific screening objective.
They can:
- Find patients who may be due for screening
- Identify gaps in care
- Recommend screening and chronic disease management projects
- Support quality improvement work in your clinic
Patient Care Coordinators help reach patients and plan their care.
This may include:
- Booking appointments
- Updating charts
- Gathering hospital transfer information
Our PMH team tracks project progress and keeps the members they are working with informed, helping clinics focus efforts on the patients who may benefit most.
Outreach and screening is available to Enhanced and Comprehensive members. Standard members with a family practice panel can contact their Physician Liaison to discuss their membership options.