After we worked out the kinks in communicating with the providers, we turned our attention to the patients. One of the big problems in diabetes care is that the patients frequently don't get their tests on time. We stimulate the practices by sending Practice Reminders when the patient is overdue for tests. We also stimulate the patient by mailing them a letter at the same time. The letter is produced by our computer, but it has the name and address of the practice and is sent on behalf of the patient's personal provider. (It can even have the logo of the sponsor such as the insurer or the practice group or a state agency.) It lists all the diabetes tests and when they are due and asks the patient to call the practice to set up testing.
A full size version is here.
These letters stimulate the patient to call the office and get back in care. They inform and activate the patient while the Practice Reminders prepare and activate the practice team, just like the Chronic Care Model says we should.
Direct outreach in this way has also turned out to be a huge patient satisfier. They just love getting these reminders and we have gotten many calls and notes from patients thanking us for the service.
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