Now in its fifth year, UConn Health’s population health team continues on a mission to break down barriers to care.

What started as a department of one when Khadija Poitras-Rhea, assistant vice president for population health, arrived to establish it in 2019, it’s now a group of 20, including three clinical patient navigators, three community health specialists, two social workers, two nurse educators, a pharmacist, a data scientist, an analyst, and a management team.

“We collaborate with care teams daily to improve health outcomes and address social needs for our patients,” Poitras-Rhea says. “Our team motivates our patients to take an active role in managing their health and provide support and compassion during challenging times.”

Obstacles to care may include transportation, affordability of medication, food or nutrition deficiency, or an absence of caregiver support in the home.

For those whose challenges are compounded by more complex needs, such as a chronic condition or a new diagnosis, the population health team provides care management resources to help them manage those needs. Sometimes it’s as simple as staying in regular contact with patients to remind them to keep their appointments or keep them on track with preventive care goals.

A notable example of the difference the population health team can make is the story of how it helped a patient overcome challenges of homelessness and chronic health problems. He’s lived in his own apartment in the two years since.

Leadership is not about your title, it’s about how you motivate others, mentor emerging leaders and influence change.
— Khadija Poitras-Rhea

In this line of work, leadership has added importance. Poitras-Rhea provides direction to a team whose members, in turn, provide direction to their patients.

“Leadership is an integral value that has tremendous impact on organizations, teams and individual employees,” Poitras-Rhea says. “A true leader is collaborative and skilled at aligning teams to reach a common goal. Leadership is not about your title, it’s about how you motivate others, mentor emerging leaders and influence change. The population health team embraces these core values.”

And she believes in leading by example.

“It is important for my team to know that I am committed to this work and I’m willing to work alongside them to accomplish our goals,” Poitras-Rhea, herself a licensed clinical social worker, says. “I try to make sure my team understands how their work impacts ‘the big picture.’ We review our metrics quarterly, celebrate success and look for ways to improve. Communication is key.”

Under her leadership, Poitras-Rhea’s group’s recent accomplishments include:

• Achieving a score of 94.7 (out of 100) in the Center for Medicare and Medicaid Services (CMS) Merit-based Incentive Payment System, an assessment of a medical group’s performance on the quality of care, overall cost and interoperability requirements.
• Obtaining more than $2.5 million in shared savings, care coordination payments and quality incentives for the fiscal year ending June 2022.
• Expanding UConn Health’s social determinants of health screening programs to include a pilot in the labor and delivery unit to support new Joint Commission and CMS requirements for increased screening and addressing health disparities.
• In collaboration with the UConn Health Department of Psychiatry, increasing patient access to mental health services by embedding psychiatrists in nine primary care practices.

Additionally, UConn Health is joining a national accountable care organization (ACO) through Signify Health, a health care platform that creates value-based payment programs. Starting Jan. 1, UConn Health will work with a network of physician groups to collectively reduce avoidable costs and improve health outcomes for the traditional Medicare population.

The population health team is a diverse group that serves a perhaps even more diverse population, which provides another leadership opportunity.

“Representation matters,” Poitras-Rhea says. “It is important for women, people of color, and any underrepresented group to see someone who looks like them that is accomplishing their goals. The goal may be obtaining a graduate degree, transitioning into a new role, or securing a leadership position. It is important that we mentor the next generation of diverse leaders and inspire others along the way.”

And one of Poitras-Rhea’s greatest sources of pride is how her group works together.

“The population health team not only supports patients but also each other, whether it’s encouraging a co-worker to enroll in a class or listening and providing feedback on a complex case,” she says. “They truly are a phenomenal team.”