Institute for Healthcare Improvement: Use the Patient Registry to Proactively Review Care and Plan Visits

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Delivery System Design:

Use the Patient Registry to Proactively Review Care and Plan Visits

To institute proactive care, review the registry to identify population-based needs (e.g., eye and dental exams) and plan group visits/ mailings/ fairs/ reminders to patients to meet those needs.
Use planned visits. The provider care team:
- Identifies diabetic patients coming in for an appointment the next day.
- Looks at registry data and identifies needs on flow sheet/visit note/encounter note.
- Plans visit, including who will draw labs, make referrals, and do self-management goals.
Use care flow sheets, charting templates or similar tools to guide care and follow-up. (See Clinical Information System.)

Tips

Use the reports from the registry that can answer the many patient care-related questions (e.g., "List all patients who have not had an HbA1c in 6 months".)
Schedule regular staff time for population review.
Look for areas for improvement, e.g., smoking cessation, blood pressure control, and foot exams.
Use daily huddles for staff to communicate patient needs.
Use daily care team meetings to prepare for the day's planned visits.
Consider having patients come in a few days before an appointment for blood draw so that lab results are available at the time of the appointment.
Consider "one-stop shopping" appointments with multiple providers for patients with many overdue needs.
Use mail merge software for mailings/reminders.



Measures How to Improve Results - Improvement Stories

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