Population Health Program

AmeriHealth Caritas New Hampshire's Population Health program utilizes a person-centered approach that prioritizes listening to and respecting member and family choices, including cultural, spiritual, and linguistic preferences. The six core components of the program are described below. We appreciate your assistance in letting our members know about these components and informing us if any of our members could benefit from this additional support.

Rapid Response and Outreach Team

Assists members in accessing needed health care by identifying and decreasing barriers to care. The team addresses the needs of members, supports providers and their staff, and performs functions such as:

  • Receiving inbound calls from members and providers.
  • Conducting outreach activities.
  • Conducting Health Risk Assessments (HRAs) and social determinant of health screenings.
  • Providing care coordination support to address barriers to care.
  • Coordinating value-added servcies.

Members and providers may request Rapid Response and Outreach Team support by calling 1- 833-212-2264.

Pediatric preventive health care

Designed to improve the health of members under age 21 by increasing adherence to Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) guidelines. We identify and coordinate preventive services for these members, especially when a member is due or overdue for an EPSDT service.

Bright Start® (maternity management)

Designed to assist expecting mothers by promoting healthy behaviors and controlling risk factors during pregnancy. The program is based on the prenatal care guidelines from the American College of Obstetricians and Gynecologists (ACOG). As we identify pregnant members, our staff works to help ensure that each is aware of the services and support offered through the Bright Start program.

Transitional care management

Coordinates services for members with transition of care needs. Care Managers who are licensed registered nurses or licensed mental health professionals support members by providing resolution for issues relating to access, care coordination, and follow up-care with a provider after hospital discharge. If longer-term or complex care support is needed, members are referred to care management.

Complex care management

Serves members identified as needing comprehensive and disease-specific assessments, along with the development of person-centered goals incorporated into the member’s person-centered plan of care. Care Managers who are licensed registered nurses or licensed mental health professionals work with members to develop person-centered plans of care to address the member’s goals.

Care coordination

Addresses members' health care needs while assessing for and addressing social needs and barriers and providing hands-on coordination. Care Managers and Care Connectors connect members to needed health care and community-based services.