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Population Health

Discover What Sets Us Apart

At Spring Hills, we believe that a strong support system is the key to health and happiness. It is a simple concept, but it makes a world of difference in how we operate. Twenty years of caring for seniors and patients with chronic health needs has taught us something that the healthcare system often overlooks: people respond to people. Patients who feel connected and accountable to a caregiver are more likely to follow a care plan than if they are simply instructed to record adherence in a device. At Spring Hills, advanced technologies are used to inform and enhance – not replace – person-to-person clinical care. The more frequently a patient is seen face-to-face, the more likely troubling symptoms will be caught before becoming more serious issues. Providing this kind of personal support – with patience and compassion – makes a difference for the families who rely on our Post-Acute Care, Assisted Living and Memory Care communities, as well as our Home Care services. Every patient’s care plan is designed to meet their unique clinical needs and personalized goals. We are dedicated to Caring with a Commitment to Quality™, giving our patients and their families the resources, education and support they need to live healthier and happier lives.

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Population Health: Raising the Standard of Care

Fully integrated into our clinical programs, Spring Hills Population Health puts every patient at the center of a care plan designed to meet their unique clinical and social, economic and environmental needs using the best resources available in the most appropriate setting. Our purpose is not simply to get patients healthy, but to proactively provide the support they need to live healthier lives.

Our Population Health associates build relationships with the patient and family before their arrival to ensure a smooth transition to Spring Hills and provide support during their stay and for 90 days after returning home. This dedicated service includes care coordination, personalized communication and the assurance of safe, seamless transitions at every step of the way.

Benefits of Population Heath

24/7 Clinical Call Center
Access to A Nurse
Social Work Assessments
Medication Review & Reconciliation
Disease Specific Education & Coaching
Care Coordination & Recommendations
I was very happy to have the support of Spring Hills Population Health after receiving Physical Therapy at the rehabilitation facility. I was contacted weekly by staff assigned to follow my progress. They provided guidance to help me to ask the right questions when I met with my Primary Care Physician. It was an excellent experience and I would recommend Spring Hills Population Health to all. -Spring Hills Population Health Patient

Our Solutions

Spring Hills Post-Acute Care, Assisted Living, Skilled Nursing and Memory Care communities and Home Care Services provide comprehensive support, including population health management, to offer patients and residents uniquely comprehensive health services and solutions.

Spring Hills Population Health includes the design, delivery, coordination and payment for high-quality healthcare services using the best resources available — such as accountable care organizations (ACOs), risk stratification methods, patient registries and patient-centered medical home as well as other models of team-based care.

Spring Hills Population Health leverages Artificial Intelligence (AI), which allows us to anticipate the likely course of a patient’s health condition and create a care plan to bypass known risks and pre-emptively meet their needs. Additionally, our utilization of machine learning algorithms to focus on defined groups of patients experiencing common medical conditions and risk factors enable personalized engagement and targeted interventions along the entire continuum of care, including:

  • Initial patient assessment, including the identification of unmet social needs
  • Risk stratification for clinical, social, behavioral and medical cost factors
  • Integrated case management
  • Comprehensive education
  • Digital case management and continuous patient engagement
  • Remote monitoring of physiological parameters and telemedicine
  • Coordination of medical transportation
  • Urgent care visits
  • Mobile care
  • Palliative and hospice care

Post Acute Care

Our multidisciplinary care team works with the patient, the family and the patient’s physicians to create a comprehensive recovery and rehabilitation plan that fulfills the patient’s unique clinical needs and personalized goals. Advanced technologies are used to inform and enhance — never to replace — person-to-person clinical care. We are with our patients at every stage of their journey, so they can go home quickly and stay safe once they get there.

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Home Care

Our Home Care solution provides the flexibility, personalized support and proactive approach that enables individuals to live safely in the comfort of their own home. Our Certified Home Health Aides (CHHAs) are trained to care for those with chronic illnesses and conditions such as dementia, osteoporosis and cardiovascular disease. We offer condition-specific education, exercise programs and other assistance to help individuals manage their condition while living where they feel most happy and comfortable.

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Assisted Living

Our distinctive Assisted Living communities are designed to surround our residents in comfort, warmth, and elegance. Our Signature Touch philosophy allows seniors to have access to engaging programs and activities while receiving the personalized attention that they need — when they need it. With a thoughtful eye to each resident’s individualized care plan (ISP) and preferences — and a holistic approach to move the body, intrigue the mind and inspire the spirit — our associates will know when to step in and when to let you lead the way. Get the assistance you need to meet each day with confidence.

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Memory Care

The Spring Cottage Memory Care Environments are designed to support and encourage our residents with Alzheimer’s Disease and dementia. We create a tailored atmosphere of positivity, engagement, flexibility and security to address each resident’s specific needs, even as those needs change over time.

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All the Components for a Continuum of Care

“Comprehensive population health management fills critical gaps in the patient journey. It also provides connective tissue for our fractured healthcare system. Advanced information technologies and artificial intelligence allow us to anticipate the likely course of a patient’s health condition and create a care plan to bypass known risks and meet — or even pre-empt — their needs. Further, these technologies allow for scaling best practices of care to fulfill the requirements of value-based and bundle reimbursement contracts.”

— Dr. Pierantonio Russo
CMO & Chief Clinical Transformation Officer
Spring Hills Population Health

“We vet all of our preferred partners and hold them to our high standard of care. We create integrated workflows, have weekly meetings to discuss our common patients, and require monthly reports on outcomes. Maintaining open, regular channels of communication with our partners is as important as our clinical teams’ doing so with patients’ own physicians and caregivers. Ensuring that we all stay aligned around fulfilling the patient’s needs is what patient-centered care is all about.” Gloria Berwick, Vice President of Operations, Spring Hills Population Health

Our Partners

Spring Hills is committed to improving outcomes for our patients and our physicians, health system and health plan partners. We have invested in the infrastructure, technologies and multidisciplinary care teams needed to provide hospital-level care in a post-acute environment. By increasing the frequency and depth of clinical care and monitoring, we decrease the length of stay; reduce the risk of post-discharge complications, hospital readmissions and ER visits; and lower the costs of care, thereby providing measurable value for patients and caregivers, doctors, hospitals and insurers. If you’d like to partner with us, please fill out the form below.

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