Assignment:
You are a team of population health management consultants, hired by a large not-for-profit healthcare system. The covered population has a high incidence rate of obesity and diabetes. Based on income, education, and occupation, the community is characterized as being in the middle socio-economic status level. Twenty four percent of this healthcare system's patients are on Medicaid, and 32% are on Medicare. Include approaches addressing gaps in care coordination and effective management of hypertension through a focus on team-based care, patient engagement, and effective use of health information technology tools.
Be sure to include in your recommendations' details about the development of a community health promotion program addressing the risks associated with hypertension. Include specific approaches aimed to increase patients' hypertension self-management skills, have patients to adhere to home BP monitoring, ensure patients' understanding of and adherence with medication regimens, and ensure continued patient follow-up and communication with their primary care provider.