Accountable Care Organization patient centered medical home

Population Care Coordinators: Coming to a Practice Near You.

For the last several days I’ve been researching an innovative program by Horizon Healthcare Innovations, a subsidiary of Horizon Blue Cross Blue Shield of New Jersey, challenged with transforming New Jersey’s healthcare delivery system. I’ve been learning about the Population Care Coordinator Program that Horizon developed in partnership with the Duke University School of Nursing and Rutgers College of Nursing. The program plans to train at least 200 nurses over the next two years to be Population Care Coordinators in primary care practices throughout New Jersey. This pioneering venture gives nurses formal training to support the Patient-Centered Medical Home (PCMH) Program and other innovative, population-based health programs. The training program, which is approximately 12 weeks, is being delivered in an online format supplemented with three intensive face-to-face sessions: one at the Duke campus and two at the Rutgers campus. Although the initial program is taking place in New Jersey, it is believed that this program could develop into a national model.

Population Care Coordinators are nurses who work in Primary Care Physician offices, and help improve the coordination of care for patients. Working closely with primary care doctors and care teams, these care coordinators follow up with patients to address their needs, continuously update personalized health plans and help engage and empower patients. Many nurses who complete this new training will be working in new patient care models, such as the Patient Centered Medical Home (PCMH) Program, helping practices transition to this new model of care. At a time when healthcare organizations (payers and providers) are faced with the challenge of improving patient outcomes while reducing costs, the opportunity for a care coordinator to proactively interact with patients at particular risk of chronic disease, makes a lot of sense. The care coordinators can help patients avoid unnecessary visits to the ED and unnecessary hospital admissions, and encourage patients to better manage their health while being more adherent to treatment (for example, take their medication as prescribed or follow a specific diet). Below I’ve inserted a brief video of current Population Care Coordinators. The video was produced by Horizon Healthcare Innovations.

Within the Horizon program, the population care coordinators will work in medical practices that are partnering with Horizon Healthcare Innovations, which is paying the cost of training the nurses, and providing a subsidy to the medical practices to help cover the costs of hiring the nurses. The population care coordinators will actively mine patient data, identify gaps in care, and contact patients to initiate action designed to close those gaps. That may include the patient participating in preventative care and undergoing overdue diagnostic procedures such as a colonoscopy, mammogram, blood pressure or cholesterol screening.

To read the full press release announcing the launch of the new Population Care Coordinator Program, click here. To visit Horizon Healthcare Innovations’ website and read more about the program, use this link. To read about Duke University School of Nursing’s Population Care Coordinator Program, visit

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