Population Health

Population Health

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

Chronic Care Management

Chronic Care Management (CCM) is a patient and family-centered program that assists people living with one 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.


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.

Population Health

Population health is an interdisciplinary approach that looks at the health outcomes of a group of individuals, whiling aiming to improve the health of the entire population. Mammoth Hospital’s Population Health Department not only works closely with the clinics, but also partners with different sectors of the community such as public health and state and local government to achieve positive health outcomes in our community.

Caravan Health ACO

Mammoth Hospital participates in a Medicare Shared Savings Program Accountable Care Organization (ACO).

What is an ACO?

ACOs are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high-quality care to their Medicare patients.
The goal of coordinated care is to ensure that patients get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors.

When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, the ACO will share in the savings it achieves for the Medicare program.

Where can I learn more about ACOs?

CMS offers different learning opportunities for providers and organizations interested in learning more about ACOs. Visit the CMS Innovation Center website and Medicare Shared Savings Program website periodically to learn about the latest opportunities.
Visit the Medicare fee-for-service Frequently Asked Questions for more information on the Medicare Shared Savings Program.

Quality Measures

As part of the Medicare Shared Savings Program, the Population Health Department completes reporting for Quality Measures. CMS rewards ACOs with shared savings when they are able to lower growth in Medicare Parts A and B fee-for-service (FFS) costs while also meeting performance standards on quality of care. Before an ACO can share in any savings, it must demonstrate that it met the quality performance standard for that year. These measures include span four key domains: patient/caregiver experience, care coordination/patient safety, preventive health, and at-risk population.