Population Health Program

CGHC has Population Health management (PHM) programs and activities to improve the health of CGHC’s member population. CGHC’s PHM programs and activities are reviewed, updated and approved by CGHC’s Executive Quality Oversight Committee (EQOC) at least annually.

CGHC’s PHM programs and activities include specific areas of focus that address the following below. CGHC will notify specific members who qualify for these programs via mailing in addition to interactive communications including phone calls, face to face when possible, and/or or text messaging

Keeping members healthy: 

• Children and Adolescent Preventive Care: CGHC children and adolescents to receive their necessary preventive services from a contracted CGHC practitioner’s office or contracted pharmacy, at no cost.
• Adult Preventive Care: CGHC adult members 18 and older to receive their necessary preventive services from a contracted CGHC practitioner’s office or contracted pharmacy, at no cost.

Managing members with emerging risk

• Statin Therapy for Members with Diabetes: CGHC members with a confirmed diagnosis of diabetes, ages 40 to 75 to start and continue taking a statin medication to control individual cardiovascular risk factors by preventing or slowing Atherosclerotic Cardiovascular Disease.
• Diabetic Eye Exams: CGHC diabetic members to receive the necessary diabetic eye exam to detect eye problems such as diabetic retinopathy, glaucoma, and other eye problems early.
• Medication Management for Members with Asthma: CGHC members diagnosed with persistent asthma ages 5–64 years of age to continue taking their asthma controller medication to reduce airway inflammation and help prevent asthma symptoms from occurring.

Patient Safety – Improve the safety of high-alert medications

• CGHC’s Opioid Management Program: CGHC members who are “first fill” opioid utilizers to receive education and discussions with a pharmacist to prevent inappropriate utilization.
• Monitoring Members on Warfarin Therapy: CGHC members who are dispensed warfarin for at least 56 days receive at least one international normalized ratio (INR) monitoring lab test, for each 56-day interval with active warfarin therapy to reduce the occurrence of preventable adverse drug events.

Managing multiple chronic illnesses: 

• CGHC Members Enrolled in Complex Case Management: CGHC members who are currently enrolled in Case Management who had an inpatient stay will receive a post-discharge assessment and transition of care plan completed.
• CGHC’s In-Home Health Visit Program: CGHC members who qualify will be offered a free personalized in-home visit with a Medigence Health provider. CGHC has partnered with Medigence to provide extended visits to select members. This program offers an opportunity to review the member’s health history in the comfort of their home with a Medigence Health medical professional. The findings of the visit are then shared with the patient and their primary care physician, including any previously unidentified concerns and recommendations for services that could make managing their health easier.