Population Health

Population Health

Meet our Population Health team: Kate Britton, Kelli Moore, Diane Stevens, and Mike Miller


As part of Mammoth Hospital’s goals and objectives to support system improvements and change management, Mammoth Hospital is participating in The Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program. We chose two focus areas which align with our community needs: Integration of Behavioral Health and Chronic Non-Malignant Pain Management.

Given the rural setting of the community and the limit to professional health services, access and continuity of care is a challenge for Mono County residents. Mammoth Hospital will continue to focus on a movement towards population health management in order to better care for the health needs and disparities of those in the community. The organization as a whole is focused on better care coordination and developing programs and services to address behavioral and physical needs.

Chronic Care Management

Chronic Care Management (CCM) is a patient and family-centered program that assists people living with two or more chronic conditions better manage their conditions. The Care Coordinator RN assists in teaching self-management skills, goal setting, and effective communication with Primary Care Providers (PCP) and provides links to community resources. CCM continues for as long as the person has two or more chronic illnesses that are expected to last at least 12 months and that place a person at significant risk of death, sudden health problem onset or decline of health conditions.

Chronic care management services may include:

      • At least 20 minutes per month of CCM services
      • Personalized assistance from a dedicated health care professional who will work with you to create a care plan
      • Coordination of care between your pharmacy, specialists, testing centers, hospitals and more
      • 24/7 emergency access to a health care professional
      • Expert assistance with setting and meeting your health goals

Transitional Care Management

Transitional Care Management (TCM) is a program that provides oversight and coordination of healthcare services for patients transitioning from an inpatient hospital setting to the home. The service starts with the coordination of care between the hospital’s interdisciplinary team, the patient, family and the Primary Care Provider and continues for 30 days following discharge from the hospital. The Population Health Nurse works closely with the patient, family, Primary Care Provider, Home Health Care Staff and other Community Resources to formulate a patient-centered care plan.