Population Health

What is Population Health?

Population health is a group of providers and nurses working together with patients to help them be healthier through closer follow ups. These follow ups occur when a patient is discharged from the hospital and when they are due for testing for their chronic conditions. Our team also works with your Primary Care Provider to help manage your chronic conditions in between in-person visits with their office.

Our Approach

The Population Health team at Mount Nittany Health focuses on:

• Diabetes care
• Preventative screenings for breast cancer, osteoporosis, and colon cancer
• Transitions of care

Diabetes Care

The Diabetes Management Team offers services to Mount Nittany Health patients with diabetes. Our team of Diabetes Nurse Navigators, and a Certified Registered Nurse Practitioner, work closely with your primary care team. For more information and to meet the team, click to view our brochure.

We help patients overcome obstacles like:

• Medicine costs
• Diabetes knowledge
• Blood sugar monitoring
• Healthy diets

Population Health Treatments / Services

Our team may contact you to review your medical records for items such as:

• Latest lab results
• Eye Exams
• Dietary habits
• Exercise habits
• Glucose readings

Diabetes Preventative Care including

• Hemoglobin A1C: A blood test that measures your average blood sugar levels over the past three months, recommended every 6 months.
• Urine microalbumin/creatinine ratio: A urine test that checks for very small amounts of a protein called albumin. If present, this may be one of the first signs of kidney disease, recommended once per year.
• Serum creatinine: Blood test that measures the function of your kidneys, recommended once per year.
• Lipid panel: A blood test that monitors the amount of cholesterol and fats in your blood. Monitoring and treating this are important for cardiovascular health, recommended once per year.
• Diabetes Eye Exam: A vision test completed by your regular eye care provider. In early stages, diabetic retinopathy does not cause vision changes. These eye exams can prevent vision loss or blindness, recommended once per year.

Transition of Care (TCM)

This group is comprised of Clinical Transformation Specialists (Registered Nurses) and Licensed Practical Nurses (LPN) who provide services to established Mount Nittany Health patients who are transitioning from one care setting to another.  These transitions include hospital, skilled nursing facility, and behavioral health unit discharges to home and personal care homes.

Services

Medical Center Follow-Up

TCM contacts patients within two business days of discharge by a Mount Nittany Health RN.

The following may be reviewed:

• Patient’s current status
• Ensure the scheduling of hospital follow-up appointments and specialty appointments
• Follow-up lab work or testing
• Medication review
• Offering patients continued follow-up calls for a 30-day time frame post-discharge

Emergency Department (ED) Follow-Up

Calls will be made within three business days of ED discharge if deemed appropriate.

The following will be reviewed during the call:

• Patient status
• Further questions and concerns
• Offering of follow-up appt if one has not already been made

The goal of TCM and ED follow-up calls is to bridge the gap when a patient is moving from one facility to another.  This ensures continuity of care, fewer medication errors, and a lower rate of hospital readmissions.