If you’ve been in the hospital for the treatment of a chronic illness and need help controlling your condition, you may benefit from Valley’s Population Health program. The goal of this free program is to help you manage your condition effectively, receive appropriate, high-quality care, and avoid unnecessary hospital or Emergency Department visits. 

By working with our Population Health nurses, you can successfully manage your health and improve your overall health experience.

The Valley Approach to Population Health

At the core of Population Health is care coordination. Our team of nurses, practitioners, social workers, care coordinators and others coordinate all aspects of your care with your healthcare providers, as well as services across Valley Health System, to ensure that you receive the right care at the right time and in the right place.

The nurses also take a holistic view of your health, checking on your overall needs and working with a vast network of community resources (including programs for food, transportation and housing) to address other factors that may affect your health.

How it Works

You’ll receive a call from a Population Health nurse after your discharge from the hospital. This nurse will:

  • Educate you and your caregiver about disease self-management
  • Help you and your caregiver establish and meet health-related goals
  • Ensure medication compliance
  • Educate you on how to best communicate with your healthcare team
  • Provide education and support for navigating the healthcare system
  • Ensure a successful transition from one care setting to the next
  • Schedule follow-up visits and improve your access to care and preventive services
  • Work with members of your healthcare team to confirm that you’re receiving the appropriate level of care