Population Health
Population Health and Quality Payment Programs
The Centers for Medicare & Medicaid Services (CMS) launched the Quality Payment Program (QPP) to encourage better patient care. Instead of paying providers based only on how many tests or visits they perform, the program rewards them for helping patients stay healthier and achieve better outcomes.
North Oaks Population Health and Quality Programs track how our services are performing on key measures such as breast and colorectal cancer screening and other preventive care.
Since 2020, our department has helped North Oaks providers take part in value-based care programs that reward improved patient outcomes. Through these efforts, we deliver:
- Care coordination: Helping make sure all parts of your care are connected and working together.
- Chronic disease management: Helping you manage ongoing health conditions like diabetes or high blood pressure.
- Care transition services: Supporting you as you move from one place of care to another, like from the hospital to home.
- Complex Medication Management: Helping you understand and safely manage multiple medications.
- Longitudinal care support: Providing ongoing support for your health over time, not just during one visit.
Our team uses detailed reports to identify patients who may need extra support, find gaps in care, and look for ways to improve. This helps us provide better health outcomes, improve the patient experience, and meet value-based care standards.
Data
25,000 Lives | 36 Providers
$4.2 Million Value-Based Bonus Earning, 2022+ 2023 + 2024+ 2025
Our Results
7/7 Eligible Quality Metrics Sufficiently Satisfied
Medicare Annual Wellness Visits
Driving Better Health & Making a Measurable Impact
Medicare Annual Wellness Visits are an important part of how we help patients stay healthy. These visits focus on prevention by helping patients identify health risks early and stay on track with recommended care.
Unlike visits for illness, wellness visits focus on long-term health. They give us time to create personalized care plans and support patients over time. This approach helps improve health outcomes and can reduce unnecessary hospital visits and overall healthcare costs.
The Impact
- 90% increase in Annual Wellness Visits.
- Improved quality scores and compliance with value-based care metrics.
- Reduced ER visits.
Frontline Perspective
Click here to read on The Impact of One Phone Call in Patient Care
"As a Care Coordinator and Medical Assistant here at North Oaks for 18 years, I often see how small actions can change lives. What I value most in my job is helping create strong, supportive connections between patients and their providers.
One of my most rewarding stories is when a patient came in for an orthopedic visit with a dangerously high blood pressure reading. After reviewing her vitals, I immediately called and scheduled her with one of our primary care providers for the very next day. Because she did not have a primary care provider, her hypertension was not being managed, and she was not taking any blood pressure medications.
Today, she feels so much better. Her blood pressure is controlled, and she often tells me that one phone call may have saved her life. Moments like these remind me why this work matters. Healthcare is about connection, and sometimes a simple act can make all the difference. Every successful follow‑up and every patient who leaves feeling reassured is a victory for both the patient and our team.
Frontline work teaches resilience and empathy. It is about listening closely, acting quickly, and never losing sight of the human being behind the chart. In this role, I’ve learned that healthcare isn’t just about medicine, it’s about connection, and that is what keeps me motivated every day."
Consandra Newton, Medical Assistant
Care Coordinator
North Oaks Mobile Health Unit
Mobile Care Program
North Oaks Mobile Care brings quality healthcare directly into the community, making it easier for people to get care where they need it. This mobile clinic is staffed by our providers and offers primary care, preventive services, and health education.
The program also reaches out to underserved communities to help patients better understand their health, including topics like blood pressure, primary care, screenings, heart attack warning signs, and hands only CPR. By working closely with patients and community partners, the team helps connect people across Livingston, Tangipahoa, St. Helena, and St. Tammany parishes to the care and resources they need.
A Look at the Community We Serve
Heart Disease
217.7
per 100,000
Diabetes
13%
of population
Obesity
37.7%
of population
Region 9 | Louisiana State Health Assessment
Insights
The numbers above highlight key health concerns in Region 9 and help guide the focus of our Mobile Health Unit outreach events. In this area, 13% of adults have diabetes, 37.7% are affected by obesity, and 217.7 out of every 100,000 people are living with heart disease.
At Mobile Care events, our team provides education to help community members understand how to prevent and manage these conditions. These efforts encourage people to take an active role in their health, identify concerns early, and get the care they need, helping improve overall health across our community.
How Does the Mobile Care Program Perform?
The Mobile Care Program has been serving the community since May 2023. Since then, the program has had 6,289 encounters with the community.
- 960 blood pressure assessments.
- 940 type 2 diabetes assessments.
- 962 stroke risks assessments.
- 9,157 educational materials have been distributed to those in need.
Expanding Health Equity
Beginning in 2026, the Mobile Health Unit will launch the Care at Home initiative, a program designed to deliver healthcare services directly to patients where they live. This approach strengthens relationships with primary care providers and helps reduce preventable hospitalizations by offering convenient, accessible care.
By meeting patients where they live, we aim to:
- Reduce transportation barriers that can delay or prevent care.
-
Improve access to primary care and strengthen ongoing relationships with providers.
-
Prevent avoidable hospital visits through early care and consistent support.
This innovative approach ensures patients receive the care they need, when, and where they need it. By increasing access, enhancing continuity of care, and supporting early detection, the Care at Home initiative improves overall health outcomes.
Communicating Clearly with Patients
The Mobile Care team creates a safe and supportive place for patients to learn about their health. This helps people better understand their risk for conditions like stroke, heart disease, and type 2 diabetes, and encourages them to take an active role in their care. Through clear education and communication, we support patients in managing their health and reducing the risk of preventable conditions.
How Can You Request North Oaks Mobile Care for Your Event?
Go to North Oaks Mobile Care: Quality Healthcare on Wheels and complete the form listed on the webpage.