Population Health Management

SCCP is uniquely positioned to provide comprehensive, person-centered, population health management services, for high-risk and high-cost populations. Our integrated ecological model aims at addressing the inter-relational aspects of physical, psychological, and social determinants of health status, through providing a comprehensive array of coordinated, timely, and accessible services that are culturally competent. These services are provided by Clinical Care Managers (RNs, LCSWs) with support from Navigators (CNAs, CMAs, Community Health Workers).

Our population health management services include:

    • Onboarding New Health Plan Members
    • Health Risk Screenings/Assessments
    • Care Planning
    • Health Education/Health Literacy Activities
    • Monitoring and Tracking of Treatment Adherence
    • Discharge Planning and Transition of Care Support
    • Chronic Care Management
    • Medication Management
    • Navigator Support
    • Addressing Social Determinants of Health
    • Linking Members to Community Resources
    • Appropriate Reporting