Care Transitions in Population Health

Parkview Health in Fort Wayne, Ind., began its journey in chronic care management in 2013 with a thorough assessment of need and scope of services. Over the next two years, a high-risk-patient-self-care program was developed with the needs of high-risk chronic disease patients, as well as “at-risk,” community-based-care clients as a top priority.

This webinar will follow Parkview’s progress as they share risk for populations and the continuous growth of their population health care management programs. It also will describe the multiple approaches taken to identify high-risk populations and how to build a physician-led care management program to support the patient in personal self-care.

Learning Objectives:

  • Identify high-risk populations
  • Describe the correlation between chronic disease and community-based care
  • Evaluate care strategies
  • Describe measureable outcomes


  • Susan McAlister, Director, Enterprise Care Management, Population Health, Parkview Health
  • Christine Howell, Nurse, Community Navigation, Parkview Health