Population Health—A Tool to Help Medical Home Teams Address Prevention

BACKGROUND: Assessing and addressing preventive screenings at every medical home visit is critical to ensuring highest quality care to patients. Ideally, accurate and up to date prevention screening data should be available to clinicians from AHLTA and this data should match that which is in the Military Health System Population Health Portal (MHSPHP). However this is not always the case, especially when care is provided downtown or in a VA facility. Patients also self report screenings that are not captured in the MHSPHP data. As a result, it is difficult to have one source that accurately reflects the patient’s true status of prevention screenings. Additionally, clinicians and leadership are frustrated that quality performance measures do not seem to fully reflect the care that they believe they provide.
IDEA:This initiative provides a simple tool based on MHSPHP and ASIMS (AF Medical Readiness Portal) data to allow medical home staff members who are checking in patients to see the status of specific prevention screenings (PAP, mammogram, colonoscopy, diabetes labs, AND medical readiness items for active duty members) in one spot. We use a paper-based report but it could be web-based as long as it shows all patients with scheduled appointments on a specific day in one location and does not require individual patient look up. Patients who are not in a cohort requiring any of the covered screenings are not included on our sample sheet.
OUR USE OF TOOL: The screening data is transferred onto the TriServiceWorkFlow (TSWF) template in AHLTA and missing items are addressed during the visit. A standardized matrix of staff actions was developed, approved, and trained to Family Health Clinic staff. (e.g. A release of information request is completed to request copies of care accomplished downtown that is not already captured by the MHSPHP). Staff members annotate the actions they take on the paper copy and hand the sheet in to the Health Care Integrator (population health nurse) for review and tracking. When applicable (e.g. paper copies of downtown records received, patient refusals annotated in AHLTA, etc) the test is added in the MHSPHP or the patient is excluded from the MHSPHP. The result is that the prevention screening data is updated in the TSWF, prevention screening is addressed and communicated in a standardized way, and Medical Home metrics computed by the MHSPHP provide a more accurate picture of the quality care provided.

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