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Population Health Outreach & Care Coordination

Population Health Outreach & Care Coordination

The primary goal of Population Health Outreach & Care Coordination at CCNC is decreasing emergency department (ED) utilization. To accomplish this, our team uses real-time hospital data to identify and contact patients linked to a CCNC provider who have had a recent non-emergent visit to the ED. Through interaction with patients, CCNC staff emphasize the importance of using a medical home, identify any needed follow up, and links patients to local resources in their communities. While most outreach efforts are made to the patient only once, RNs on the Population Health Outreach & Care Coordination team may attempt to reach out to patients who continue to over-utilize the ED. Members of our team assess these patient situations closely to identify gaps in care and/or new issues that can be referred to CCNC care managers for assistance.

"CCNC's Outreach & Care Coordination team has
provided approximately 195,000 patients with information
on medical homes and their Medicaid benefits."

Debbie Murray, RN, CMAC, CHC, CPN, CNM

Director of Outreach and Care Coordination Services


CCNC's Population Health Outreach & Care Coordination team also provides information to newly enrolled patients on:

  • Appropriate ED use
  • Urgent care utilization
  • Local resources in their communities 
  • Information specific to their medical home provider
  • Co-pay for visits or prescriptions
  • How to access specialists

This type of population health outreach is provided primarily to patients who have been enrolled within the past 90 days, had an ED visit within the past 90 days and are currently classified as a CCNC priority patient. Future goals for this initiative include focusing these calls on all patients enrolled in the past 30 days.

Additionally, CCNC's Population Health Outreach & Care Coordination team offers health coaching to the CCNC Medicaid population. RNs who are also certified health coaches work with patients referred to them on wellness coaching and disease management coaching. Coaches use their experience and skills to motivate patients to accept responsibility as primary care taker of their own health and wellness by setting and reaching health related goals they set for themselves. 

CCNC makes more than 10,000 call attempts each month. Data is collected on a number of items that can be shared with CCNC networks and with primary care providers. As new programs emerge, networks continue to evolve, and new patient needs develop, CCNC's Population Health Outreach & Care Coordination Services will continue to further define its processes to assure that staff is reaching patients that they can most impact.