Population Health—It Takes An Entire Medical Group


Making the most of EVERY patient encounter is critical to ensuring patients receive recommended preventive screenings. The focus on prevention occurs mainly in medical home clinics where primary care takes place. This works well when all enrollees receive their primary care at the MTF, but many locations have enrollees who choose to use more than one source (e.g. VA, other health insurance) for some or all of their routine care. Larger MTFs, especially those that provide specialty and inpatient care, have many patient contact points and some enrollees use MTF specialty clinics with few or no primary care visits. This initiative seeks to expand population health efforts into some or all specialty areas. Requirements: • It must be simple and add little or no additional work on the existing staff.
• The source data must be the same as what is used by the Military Health System Population Health Portal to generate the HEDIS/Medical Home performance metrics and generate the Population Health Action Lists.
• Ideally the data should be displayed as part of the AHLTA record.

There are various ways to accomplish this concept and I provide a sample decentralized process below. Another idea is to have a centralized desk in the main entry way and ask patients to check in at that desk as they enter the facility. The desk could be utilized to assess and educate patients on their preventive screening status as well as to complete a variety of important administrative functions such as to confirm proper demographics, complete third party collection forms, assist patients to complete the sign-up process for Secure Messaging.

SAMPLE PROCESS: The 673d Medical Group at Joint Base Elmendorf-Richardson completed a pilot test of this concept using a decentralized process in 3 specialty clinics between May-Nov 2012. Each Friday the Health Care Integrator (HCI), the nurse champion for population health, identified those patients who were missing PAP, mammogram, and/or colonoscopy AND had an appointment scheduled the following week in the Optometry/Ophthalmology, Mammography, or Orthopedic Clinics. She ran an individualized Patient Prevention Reminder sheet for each patient (shown above) and attached a yellow, wallet-sized card listing missing prevention items and phone numbers and instructions stating how to schedule or fax results. Sheets were taken to the front desk of the test clinics. Staff handed the sheet to the patient during check-in and then collected the completed sheet from the patient. The sheet allowed patients to communicate important information about the testing back to clinical staff. Patients then kept the yellow card as a reminder. Completed sheets were picked up and reviewed each week by the HCI. Based on patient response actions were taken to schedule testing, obtain results or other as applicable. Outcome data currently being compiled.

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