Population Health Management

Hometown Health Population Health Management

Hometown Health’s Population Health Management program identifies the health risk of members, based on a standardized assessment process, to determine who may benefit from additional support and services.

We provide individual targeted services that promote health, wellness, and improved member well-being. By providing members with the best care possible by assisting them with:

  • Care management services that assist members’ managing health issues.
  • Transitions of care coordination.
  • Getting the care, they need when they need it.
  • Address members’ language and cultural needs
  • Reduce barriers to getting care, such as issues with transportation and/or language challenges.
  • Provide health information and remind them about preventive services and routine check-ups.
  • Offer a variety of health and wellness education and information.

Care Management

Personal care management is a care management service for members 65+ who have multiple chronic illnesses or have DSNP coverage. The program offers individualized assistance for members experiencing challenges associated with having chronic conditions. Care management is a team based, patient-centered approach that assists the member and their family in managing health concerns more effectively. Care management also provides care coordination to help manage seeing multiple providers.

Services offered:

  • Provide health education and resources focusing on the members health goals and priorities
  • Medication review
  • Assistance with coordinating healthcare and services
  • Assistance with making appointments
  • Connecting members to community services

To be eligible for this service, you must either be on a Senior Care Plus DSNP Plan or have one or more chronic conditions. Your provider may send a referral to the Complex Case Management Program if they feel you would benefit from our services. If you feel like you would benefit from these services, please discuss with your primary care provider and ask for a referral to this program.

Transitional Care Management

Hometown Health’s Transitional Care service helps to prevent health complications post-hospitalization by assisting members get to the right level of services and avoid re-hospitalizations, by providing at risk members with whole person comprehensive discharge planning and follow-up care. This service includes the patient and care givers in the care planning process.

The components of transitional care services consist of:

  • Assistance with medication management
  • Transitional planning
  • Patient and family education
  • Communicating and transferring information
  • Assuring follow-up care

All member being discharged from an acute care facility are eligible for this service.

Members can access Care Management or Transitional services by calling 775 982-7222 or 775 982-3112

  • At any point in time members would no longer care to participate in the programs they can let their care manager know or by calling 775 982-3112 or 800 336-0123


Health and Wellness Education

Hometown Health care about the wellbeing of their members and families, offering resources to help keep you healthy as well as how to manage chronic conditions.

In partnership with our parent company, Renown Health, we offer access to a detailed Health Library with health resources are available on prevention, staying healthy, and chronic conditions.  You can access the Renown Health Library here.  You can also access our Patient Education Library here.

Hometown Health and Senior Care Plus Member Outreach Program

The Hometown Health and  Senior Care Plus Member Outreach Program is a proactive initiative designed to ensure our members receive comprehensive healthcare by actively closing gaps in care. Through this program, our dedicated coordinators reach out personally to members via telephone or MyChart to facilitate essential healthcare services such as cancer screenings, immunizations, comprehensive health assessments, and annual wellness visits.

One of the key strengths of our program lies in the seamless coordination between our plan coordinators and the medical group. Utilizing the same electronic medical record and scheduling system, our coordinators can efficiently act on behalf of both the plan and the medical group. This integrated approach ensures a smooth process from outreach to the delivery of results, minimizing any potential gaps in communication or care.

The Member Outreach Program is interactive and personalized. Our coordinators not only schedule appointments but also provide education on the importance of the outreach initiative. They guide members through the process, addressing any concerns or questions they may have along the way. Additionally, our coordinators ensure that all relevant information is relayed to the members’ healthcare providers, facilitating continuity of care.

We understand that healthcare is personal, and members have the autonomy to opt out of outreach initiatives at any time during the call. Respecting individual preferences and choices is fundamental to our approach, and we strive to provide a supportive and patient-centered experience for all our members.

Through proactive outreach and personalized support, the Senior Care Plus Member Outreach Program aims to enhance the overall health and well-being of our members, ensuring they receive the quality care they deserve.

Current Member Outreach Initiates for  Hometown Health and Senior Care Plus Members

Comprehensive Health Assessment (CHA)Every SCP member who has not completed CHA in the current calendar year
Screening MammogramsWomen between the ages of 40 to 75 years old, who have not completed a screening mammogram in the last 365 days
Colorectal Cancer Screening

Individuals between the ages of 45 to 75 years old, who have not completed a screening:
Colonoscopies in the last 10 years
Fit Test in the last 365 days

Cologuard in the last 3 years

DEXAIndividuals between the ages of 50 to 75 years old, who have not completed a screening in the last 24 months.
Diabetes screenings:
Retinal Screening

Individuals with Type 1 or Type 2 diabetes
Who have not completed A1C in the last 6 or 12 months (or as medically necessary)

Who have not completed Retinal eye exam in the 12 months (or as medically necessary)

AWVEvery SCP member who has not completed AWV in the current calendar year with their Primary Care Provider

All members are automatically eligible and enrolled in our Gaps in Care Outreach Program.

  • If you have a preference on how you would like to be contacted or would prefer not to receive these notices call 775 982-3112 or 800 336-0123 and let the customer service representative know your preferences.

Follow Up After an Emergency Department Visit:

Hometown Health and Senior Care Plus care greatly about your health and hope that you never need to use one of our Emergency Departments. However, if you find yourself at one of our contracted facilities, we have Registered Nurses available to assist you coordinate your care to ensure that you are well taken care of after your visit. After your Emergency Department visit, a Hometown Health Registered Nurse may call you to check in on you and assist you with getting the appropriate follow up care and provide you with any post discharge education or support that you need.

All members who are discharged from an in network Emergency Department are eligible for this service.

  • If you have a preference on how you would like to be contacted or would prefer not to receive these notices call 775 982-3112 or 800 336-0123 and let the customer service representative know your preferences.