Recommended Citation
Sundberg G, Yacoob Z, Quirke S, Patel D, Vo T. Population Health "Pop Spotting". Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Abstract
Background/Significance:
Various gaps persist across communities due to barriers that prevent patients from accessing their healthcare needs. Aurora St. Luke’s Family Practice Clinic, which serves a diverse and underserved population, developed an interdisciplinary outreach model called “Pop Spotting”
Purpose:
We aim to create a model that allows the clinic team to identify patients who have multiple care gaps and have been lost to follow up. By reaching out to these patients and scheduling visits, we hope to meet health care needs efficiently and improve patient outcomes.
Methods:
This project utilizes Population Health Indicator (PHI) scores to identify established clinic patients with four or more outstanding care gaps and compiling a list of 12 patients per week who met the PHI criteria. This then resulted in outreach calls to offer in-clinic or home visits to address the healthcare gaps. The data collected included monthly PHI scores, outreach call metrics, scheduled and completed visits (both in clinic and home visits).
Results:
Between April 2024 and December 2025, 1080, patients were targeted for outreach, with 660 successful contacts, resulting in 140 clinic appointments, 42 home visits, and 40 patient panel removals due to transfer of care, relocation, etc.
Conclusion:
Initially, there were obstacles to the model with staffing turnover, which were addressed to improve accountability and interdisciplinary collaboration. Overall, the outreach allowed for a combined total of 182 additional clinic and home visits, possibly indicating “Pop Spotting” as a model to improve care access to high-risk patients and reduce healthcare disparities in underserved and vulnerable populations. Opportunities for growth include implementing this model at additional clinic sites, such as the FCC, and reinforcing the key take-away that interdisciplinary collaboration and coordinated teamwork are essential to this project’s success and delivery of high-quality patient care.
Presentation Notes
Presented at Scientific Day; May 20, 2026; Milwaukee, WI.
Full Text of Presentation
wf_yes
Document Type
Poster
Open Access
Available to all.
Population Health "Pop Spotting"
Background/Significance:
Various gaps persist across communities due to barriers that prevent patients from accessing their healthcare needs. Aurora St. Luke’s Family Practice Clinic, which serves a diverse and underserved population, developed an interdisciplinary outreach model called “Pop Spotting”
Purpose:
We aim to create a model that allows the clinic team to identify patients who have multiple care gaps and have been lost to follow up. By reaching out to these patients and scheduling visits, we hope to meet health care needs efficiently and improve patient outcomes.
Methods:
This project utilizes Population Health Indicator (PHI) scores to identify established clinic patients with four or more outstanding care gaps and compiling a list of 12 patients per week who met the PHI criteria. This then resulted in outreach calls to offer in-clinic or home visits to address the healthcare gaps. The data collected included monthly PHI scores, outreach call metrics, scheduled and completed visits (both in clinic and home visits).
Results:
Between April 2024 and December 2025, 1080, patients were targeted for outreach, with 660 successful contacts, resulting in 140 clinic appointments, 42 home visits, and 40 patient panel removals due to transfer of care, relocation, etc.
Conclusion:
Initially, there were obstacles to the model with staffing turnover, which were addressed to improve accountability and interdisciplinary collaboration. Overall, the outreach allowed for a combined total of 182 additional clinic and home visits, possibly indicating “Pop Spotting” as a model to improve care access to high-risk patients and reduce healthcare disparities in underserved and vulnerable populations. Opportunities for growth include implementing this model at additional clinic sites, such as the FCC, and reinforcing the key take-away that interdisciplinary collaboration and coordinated teamwork are essential to this project’s success and delivery of high-quality patient care.
Affiliations
Aurora UW Medical Group, Aurora St. Luke's Medical Center