Kelsey-Seybold Population Health

The Kelsey-Seybold Population Health team, along with our physicians and other providers, is dedicated to partnering with patients to assure they’re following up with recommended appointments, monitoring chronic illnesses, following their doctor’s treatment plan, taking medications as prescribed, and more.

There are many barriers to managing disease, from finances and transportation to caregiver support. This is where our Population Health team comes in. Our team of nurses, dietitians, social workers, and pharmacists work together to overcome the clinical and non-clinical barriers by bridging care gaps to achieve the best outcomes for our patients.

Kelsey-Seybold identifies and refers patients needing assistance to Population Health and a member of the team pays a home visit to perform an assessment and determine how best to help patients improve their health. Patients referred to Population Health receive this high-touch service until they show an improved level of compliance, lowered health risks, and an understanding of and ability to maintain both.