Population Health

Population Health
Population Health at KCH

Working with families and caregivers to track, aid and assess the best possible plan of care for those in transitional, chronic or palliative care conditions.

Who We Are

The Population Health Programs at Knox Community Hospital aims to ensure that patients receive high-level, integrated, and personalized care with a patient-centered approach.

The team collaborates with all care team members, no matter their specialty, role, or location. Strives for clear communication between all parties involved in a patient's care, including the patient/patient's caregiver. These elements avoid unnecessary and/or redundant tests and procedures, improving the patient experience and saving cost. Care Navigators assess all of a patient's needs - not just their immediate clinical needs.

Terri Swan, APRN-CNP
Nurse Practitioner
We.Care [at] KCH.org
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Chronic Care Management is a service provided to you by your provider, a nurse care coordinator, and other healthcare team members on a monthly basis. Under this program, you will work with this team to create the most complete Care Plan to best manage your long term health needs.

How Do I Qualify?

Chronic Care Management is available to any consenting person with two or more chronic conditions expected to persist at least 12 months that place you at risk of becoming worse.


  • A personalized Care Plan developed by you and your healthcare team
  • A minimum of 20 minutes of non-face-to-face care from your care coordinator
  • Medication reconciliation and monitoring
  • Referrals to appropriate services and healthcare
  • Management of care transitions from one level of care to another
  • 24/7 access to your care team and regular communication through your choice of method - telephone, e-mail, or your patient portal
  • Assistance in managing appointments
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Transitional Care Management refers to the coordination and continuous delivery of health services from an inpatient setting, such as a hospital or skilled nursing facility, back to the community.


  • Telephone, e-mail or face-to-face contact from your Care Navigator within two business days of your inpatient discharge
  • Regular communication by your Care Navigator for 30 days to assist in a smooth transition to home and to help prevent any unnecessary readmissions
  • Assistance with scheduling a follow-up with your primary care provider within 7-14 days of discharge
  • Communication and advocacy with home health agencies and/or community based services your are currently using
  • Support for treatment and medication reconciliation and monitoring
  • Linkage to appropriate community based services
  • Reminders/assistance with scheduling appointments with your primary care provider and/or specialist or assistance with finding a primary care provider that is right for you
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What is Complex Chronic Care Management?

Complex Chronic Care Management is available to you anytime during your illness. Remember that you can receive palliative care at the same time you receive treatments for your condition. Its availability does not depend upon whether or not a cure is viable. The goal is to make you as comfortable as possible and improve your quality of life.

You don’t have to be in hospice or at the end of life to receive palliative care. People in hospice always receive palliative care, but hospice focuses on a person’s final months.


Complex Chronic Care Management identifies and treats symptoms that may be physical, emotional, spiritual, or social. Because palliative care is based on individual needs, the services offered will differ but may include the following:

  • Relief of pain and other symptoms, e.g., vomiting, shortness of breath
  • Resources such as equipment needed to aid care at home
  • Assistance for families to come together to talk about sensitive issues.
  • Links to other services, such as home help and financial support
  • Support for people to meet cultural preferences
  • Support for emotional, social, and spiritual concerns
  • Links to counseling and grief support
  • Referrals to respite care services
  • Referrals to hospice services

Complex Chronic Care Management is a family-centered model of care, meaning that family caregivers can receive practical and emotional support in addition to the patient.

What is Complex Chronic Care Management for?

Complex Chronic Care Management is for everyone of any age who has been told that they have a serious or chronic illness that cannot be cured. Complex Chronic Care Management at KCH assists adults with diseases such as cancer, end-stage kidney or lung disease, or end-stage dementia to manage symptoms and improve their quality of life. Children and adolescents needing Complex Chronic Care Management will be referred to an appropriate pediatric palliative program.

Who is on the Complex Chronic Care Management team?

Your primary care provider (PCP), care coordinator or navigator, and any other health care provider (such as a specialist, pharmacist, nutritionist, or counselor) plays an essential role in your chronic/serious health condition. Certified palliative specialists support this team when symptoms become difficult to manage.

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