Taking on the Gulf South’s Biggest
Population Health Challenges

Roxanne Cheramie and Roxanne Chaisson conduct screenings at Ochsner St. Anne Hospital

Not long ago, receiving healthcare was a linear, reactive process. A patient got sick or injured, visited a doctor and received treatment. The next time they had a health concern, the cycle started again.

Today, we know that this approach is not the optimal way to keep people healthy. We understand that preventive care can make a significant difference in long-term health and that people of different demographic backgrounds face different health risks. When healthcare providers take these differences into account and offer proactive care, they can improve outcomes for individuals and populations overall.

This is the essence of “population health,” an area of intense emphasis across the Ochsner Health System. Ochsner is the largest health system in Louisiana, a state with high rates of chronic disease and social determinants like poverty, that contribute to health risk. That means we have a big role to play to keep people healthier, better treat chronic conditions and improve overall heath throughout our community.

“Population health is the responsibility of our whole system. No one is organizing work on health at the population level better than Ochsner and our partners. As our platform grows across the state, we have an opportunity to make a big impact.”

Dr. David Carmouche

President, Ochsner Health Network;
Senior Vice President, Community Care;
and Executive Director, Ochsner
Accountable Care Network

Approaching care from a population health perspective is helping address both the challenges and opportunities of delivering care in our state. We are integrating population health across our network in several critical ways:

Patient Registries. A major investment in Epic, our electronic health record system, has helped us better execute a proactive care strategy. Within Epic, we have created more than 25 registries, which are lists of patients who meet certain criteria, such as women who are eligible for a mammogram. Registries allow us to see which patients are due for treatments or screenings and track outreach. Best of all, we uniformly use Epic across all clinical care settings, including urgent care, which improves care coordination by avoiding duplicate tests.

Community Care Teams. Population health means not only reaching out to patients before they have a health condition, but also coordinating care among providers. Community Care teams at Ochsner align providers in primary care, urgent care and post-acute care under a single leadership structure. Teams from each of these environments meet regularly for strategic planning sessions to ensure that chronic disease patients receive the best possible care while avoiding unnecessary expenses.

Proactive Ochsner Encounters. Wellness and disease prevention are the responsibility of everyone a patient interacts with at Ochsner, including the administrative personnel who greet patients at the front desk. Through Proactive Ochsner Encounters, we have empowered more of our team members, beyond a physician, nurse or other clinician, to review a patient’s health record to see if they are overdue for any screenings or vaccinations, then remind patients of these gaps when they arrive for a visit. In many cases, screenings can be scheduled at the same time as a specialist visit, making it easier for patients to stay on top of their health.