Chronic Care Management and Primary Care Collaboration Creates Award Winning Care


When a group of dedicated healthcare workers join forces with a unified goal of improving the health of our Medicare population, while at the same time decreasing the overall cost of healthcare, you end up with award winning care for our  community! This spring, our three primary care clinics and chronic care management team received recognition as a Leader in Prevention & Wellness from SignifyHealth – a top healthcare technology and analytics company that focuses on whole-person, preventative care while emphasizing population health management.

“Receiving this award is first and foremost a surprise and an honor,” said Joleen Carper, Chief of Clinic Operations at TriState Health and recipient of the 2023 Population Health Pioneer Award. “The recognition for our Accountable Care Organization (ACO) team validates the work we have been doing for the past seven years. Being part of an ACO is definitely a ‘team sport’ that is designed with the success of the patient in mind. It is truly the patient who wins.”

Being an ACO healthcare facility means that TriState Health is committed to helping ensure our community has access to affordable healthcare and improving the health of Medicare populations. To achieve these goals, many objectives include ensuring our patients receive their annual wellness visits. Providers at all three clinics use yearly wellness visits to catch health issues early, with a focus on chronic disease management, such as hypertension or diabetes.

“Preventing or catching health issues early leads to a decrease in the amount of healthcare dollars that would otherwise be spent on managing the problem, such as medications, tests, hospitalizations, and surgeries,” said Kelly Pease, Director of Family Practice & Internal Medicine. “When you think of the number of years a patient may be managing a chronic health issue, the dollars add up quickly.”

Catching a medical diagnosis early through an annual wellness visit also decreases emergency room or hospital admissions, which also adds up to high costs of care. But, if by chance you or a loved one happens to find themselves in a situation where they end up in our ER or are admitted to the hospital, our Chronic Care Management team works cohesively with other departments to ensure you have a medical partner to assist with follow-ups or medication management.

“Sometimes our patients need transportation to their medical appointments or assistance with their medications,” said Nicole Louchart, RN and Care Coordinator at TriState Health. “There are times when they need someone to check in with them to coordinate care and identify any barriers they have. We assist with helping them find resources to obtain food or housing. We take a team approach to ensure they are receiving the best care possible.”

Our Chronic Care Management team is an extension of your provider. They specifically work closely with patients who have been identified as those who have chronic healthcare needs. It takes compassion, drive, and endurance to achieve this outstanding recognition that will impact our patients for years to come. Those that made this happen include Joleen Carper, Chief of Clinic Operations; Dr. John Merrill, DO, our ACO Physician Leader; Annual Wellness Visit Coordinators, the Chronic Care Management Team; Primary Care Clinic Directors; and every hard-working support staff in the Clearwater, Clarkston, and Lewiston Primary Care Clinics.

Thank you to each one of you for creating a better state of health and building the foundation for patient success.