Population Health

Population health management is a free service offered to the community that encompasses not only the chronic medical needs of each individual, but also the psychological, social, and financial needs. This complete perspective is attained through the use of health and wellness coaching, care management and care transitions.

Our team includes  patient care coordinators, licensed social workers, registered nurse care coordinator/discharge planners, registered nurse care managers and our Belfast Public Health nurse.

We are always working on developing initiatives and services to promote the improvement of health among the population in our area, and we will continue to work with with local agencies and partnerships to achieve shared Population Health improvement outcomes.

Find a Provider

If you’re in need of a Primary Care Provider, please call our physician referral line at 930-6766 and we’d be happy to assist you. Or you can visit our Primary Care Providers Accepting New Patients web page. 

Accepting New Patients

We use a four-pronged approach to our patient care:

  • Care Transitions
  • Care Management
  • Health and Wellness Coaching
  • Targeted Outreach

Care Transitions

This program offers nursing support for those patients recently discharged home from the hospital who do not have other support services in place. Once home, an RN will call to offer a home visit to review the following;

  • Medications
  • Hospital Discharge Instructions
  • Reason for Admission
  • Any ongoing health problems you may have
  • Additional Resource Needs
  • Confirmation of a follow up appointment 

*Additional home visits or telephonic follow up may be offered if continued need exists.

Care Management

We take a team-based, patient centered approach to our Care Management model. It is designed to help patients and their support systems in understanding their medical conditions more completely. We can help with:

  • Care Coordination
  • Chronic Disease Management
  • Complex Care Management
  • Medication Review and Teaching
  • Assistance with completing Advanced Care Directives, Insurance paperwork, Mainecare Applications, Disability etc
  • Help with other needs like:
    • Food Insecurity
    • Housing/Homelessness
    • Transportation issues
    • Medication Access
    • Literacy

Health and Wellness Coaching

Our staff can help you with healthy living lifestyle choices like nutrition, exercise, stress relief, tobacco cessation or chronic illness management.

Targeted Outreach

It’s our goal to help all patients live the healthiest life possible. We use quality data mining reports to help medical providers find patients who may be due for health screenings such as:

  • Breast Cancer
  • Colorectal Cancer
  • Depression
  • Falls
  • HgbA1c

And preventative care such as:

  • Immunizations
  • Diabetic Eye Exam
  • Tobacco use
  • Annual Wellness Visit

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