Our care coordination model is a member-centric health care delivery system, designed to provide more personalized, coordinated care for the higher risk population of our membership. We manage the health of our members through a proactive approach by surrounding them with a comprehensive care team of network physicians and clinical support staff. We work closely with our network providers and offer resources and clinical support through care coordinators to enhance member care and help ensure the best possible health outcomes. All components of our health care delivery system play a role in ensuring high-quality care focused on the member.
Care Coordinators (Registered Nurses and Social Workers)
Our medical professionals work to support our providers in managing the health of their Peoples Health patients. Our care coordinators engage members with complex and multiple chronic conditions by utilizing disease-specific assessments and creating care plans that assist in self-management goals. Additionally, care coordinators provide educational and community resources as needed. To ensure members’ needs are met, targeted outreach is done to address gaps in care and transition-of-care activities are conducted to perform medication reconciliations, educate on signs and symptoms, and ensure ordered post-discharge services have begun.
Peoples Health Medicare Center
The Peoples Health Medicare Center, at 3017 Veterans Memorial Blvd., offers an easily accessible location for members and the community to meet in-person with Peoples Health representatives. Educational programs about Medicare, preventive health and Peoples Health benefits are available, along with wellness activities. Representatives are available at the center Monday through Friday, from 8 a.m. to 5 p.m.
Regional Service Centers
We have service centers in many of our regions. At the centers, your Peoples Health patients can receive a flu vaccine and a Peoples Health comprehensive wellness assessment, which includes a physical examination and medical history review performed by a Peoples Health nurse practitioner. The assessment may also include a referral for a medication review with a Peoples Health pharmacist or a consultation with a Peoples Health care coordinator social worker to discuss other health needs and concerns. At the centers, patients can also participate in educational programs.
We also offer wellness programs and activities in senior centers across our service area. The centers provide a place where community residents can engage with other residents, as well as participate in health and wellness classes and social activities.
For more information about the Peoples Health care coordination model, contact your Peoples Health representative. Additional information about primary care tools to assist in working within the Peoples Health care delivery model is available in Section B.1 (Resources for Partnering With Peoples Health). Information on how to access other provider resources is also available in this section.