Population Health Program

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

The 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 text messaging.

Keeping members healthy: 

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

Managing members with emerging risk

• 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.
• Follow-up After Hospitalization for Mental Health Illnesses: CGHC members who were hospitalized for treatment of a mental illness or intentional self-harm will receive assistance to obtain timely follow-up care with a Behavioral Health provider within 3 days from their inpatient stay.
• Timely Prenatal and Postpartum Care: Targeting Asian pregnant women to encourage timely prenatal and postpartum care to avoid complications during pregnancy labor and delivery or postpartum period.

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.

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 with potential health conditions that 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.