Our Population Health Management team is comprised of a dedicated group of professionals including Community Healthcare Coaches, Social Workers and Community Healthcare Navigators. We aim to support providers with care coordination services for their patients. We utilize a collaborative approach to providing patient education, supporting the patient in the self-management of chronic conditions, reducing utilization, addressing psycho-social barriers to accessing care and serving as the central link to key providers as the patient navigates complex health care systems.
SFHCP Population Health programs include:
- Acute Care Transitions- Hospital to Home Program
- Post – Acute Transitions in Care Program
- High Risk/High Utilization Outreach Program
- Patient/Community Education Program
- Care Coordination – Supportive Referral Program