Provide Timely Reminders for Providers and Patients with Chronic Conditions
Improving Chronic Care: Clinical Information Systems
- Use patient treatment record forms that include services needed at time of visit. Before a visit, print out current information from the registry.
- Use the registry periodically to generate lists of patients who are missing a service or have a service that is overdue.
- Use the registry to generate lists of high-risk patients for specialized care and follow-up.
- Divide the population of chronic conditions patients into categories (e.g., ethnicity, language, insurance, needs/limits, homelessness) to identify special needs.
Decide how to handle patients with missing services. Consider using planned visits and group visits. (See Delivery System Design.)
- Use the registry to invite patients to health fairs, informational meetings, etc.
- Use the registry to identify the under-insured population to solicit for special services and medical assistance programs.
- Determine how to identify patients with chronic conditions prior to a visit, and create a process to ensure that the treatment record form is on the chart in the examining room.
- Determine if your appointment system has the capability to flag patients with chronic conditions.
- Flag charts to help identify patients with chronic conditions.
- Create a protocol for which you are going to follow up and how.
- Use lists to send reminders by mail or make follow-up phone calls. To protect patient confidentiality, do NOT use postcards.
- Use patient wallet cards to remind patients what needs to be done, when.
- Create a take-home patient summary sheet.
- Create a protocol for which patients you are going to follow up and how.
- Alert community partners to keep you updated on new ways to meet the needs of these populations.
- Have a team huddle at start of day to review that day's patients for missing services.
- Assign the role of keeping updated on community activities to a team member.
- Create electronic links between registry and mailing programs.
- Establish linkages to community wellness programs for the poor.
- Partner with existing community coalitions to build linkages to other community-based organizations.