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Your annual physical may be the only time all year when you have a face-to-face conversation with your primary care physician. To make the most of it, that appointment should focus on your physical examination, problem solving and goal setting, instead of spending valuable minutes going over items like a medication refill or a colonoscopy you need to schedule.

“We want to make sure your appointment is about your agenda,” said Doug Marx, DO, family medicine physician with the Froedtert & MCW health network and chief medical officer and vice president of the Froedtert & MCW Community Physicians practice group. “There is a team of experts supporting your primary care physician to help you keep track of screening tests, immunizations, prescriptions and family history, so you can make the most of your visit.”

Maximizing the time you can spend with your doctor by removing the inefficiencies of a visit is one of the many ways you benefit from a “population health” approach. From preventive care, to managing chronic conditions and even end-of-life planning, many health systems are creating centralized programs and processes to identify groups of patients’ needs and provide more convenient care and treatment options to improve outcomes. A strong partnership between primary care providers and other care team members is what makes this possible.

“Our enhanced clinical care model relies on the expertise of not only physicians, but also nurses, pharmacists and social workers,” said Caitlin Dunn, director of Population and Digital Health for the Froedtert & MCW health network. “Our job is to make it easy for you to take the actions that will keep you in the best possible health and make sure no one falls through the cracks.”

Proactive Care for Groups With Common Traits

Population health efforts extend beyond the individual to improve the quality of health care and health outcomes of large patient populations who share commonalities in their disease, like high cholesterol, body mass index or glucose levels, or in the difficulties they face in accessing care, such as a language barrier or lack of transportation. But, population health management is not one-size-fits-all. It relies on the electronic medical record and digital health tools, such as MyChart, GetWell Loop or Glooko®, for robust data gathering, analyzing and frequent reporting to achieve targeted disease management.

“We are looking at trends to identify gaps in care so we can be proactive about intervening,” said Mark Lodes, MD, Froedtert & MCW internal medicine and pediatric physician and vice president and chief medical officer for Froedtert & MCW Population Health and Medical Education. “From the system perspective, we’re evaluating what we can do differently and what guidelines we can implement at the point of care to close those gaps.”

An example of a population health initiative is the Froedtert & MCW Ambulatory Disease Outreach Program. Pharmacists trained in the medical management of diabetes work one-on-one with patients who have uncontrolled diabetes to help them understand their disease, manage their diet, keep track of their glucose levels and adjust their medications, all in a very short timeframe. All of this is accomplished without a visit to the doctor’s office. Once their diabetes is under control, patients resume their regular physician appointments.

Population Health Advantages

When health systems invest in population health initiatives, health care becomes less expensive overall because health outcomes are better. By catching problems before they require more extensive care, patients are getting more care outside of the costliest care settings, such as hospitals and emergency rooms.

“If we can detect cancer early, when it is stage I instead of stage IV, there is a huge reduction in cost and impact on disease and mortality,” Dr. Lodes said. “We’re putting structures in place in our care delivery to make it easier for people to stay on top of preventive care and remove any barriers.”