Utilizing EHRs and closely identifying and managing patients who have missed appointments for hemoglobin A1C are two standards of care employed by Hudson River HealthCare (HRHC), a network of 16 FQHCs that use a patient-centered team of healthcare professionals to manage its diabetic population, says Kathy Brieger, RD, CDE, HRHC’s chief operations officer.
We follow six standards of care, two of which are described here. The first standard is Enhanced Access and Continuity of Care. We adopted EHRs and used our call access 24 hours a day, seven days a week. We will implement a patient portal. We offer the culture of competent care. For over 10 years, we have done training on language use and medical interpreter use. We have designated staff members who receive training, and we have our own 12-week program. We also have a medical line that allows for translation, which is critically important. If we can’t understand our patients, and they can’t understand what we are telling them, then we can’t get them care or help. We also make sure the primary caregiver is appointed to the right patient. We are still working on this. We complete reports, which the front desk staff uses to make sure they assign the patients to the correct primary caregiver.
In Standard Two, Identifying and Managing Patients, we use ‘COGNOS®,’ a reporting system that uses information from our EHR to manage patients. This includes calling patients who have missed appointments for hemoglobin A1C. It also includes inviting people for a self-management program and even care coordination.
We are able to get a report of everyone who has a hemoglobin A1C over 9, or someone who might be smoking. Those are very useful. We also provide each site with a site quality report, which allows us to monitor quality. What are some of the issues they see? When we monitor progress every month, these quality reports and clinical data are sent to sites. In addition, the medical director for each site receives a quality report and quality data. Everyone on the team is involved with this and receives these quality reports. Therefore, everyone is transparent in terms of how they are doing on their quality.
We have done a significant amount of work with HRHC, and we are using UpToDate® for evidence-based guidelines. Providers and nursing staff can use this also. We use our strategic aims and measures using evidence-based guidelines, which are developed using evidence-based medicine guidelines, and as things change, we update those as well.
33 Metrics for Care Transition Management provides a graphic compendium of performance benchmarks in key areas impacting care transitions — from key tasks performed at hospital discharge to the prevalence of home visits in programs to improve medication adherence.