We're closing the health screening gap with outreach

December 06, 2016
ClinicalOutreach_thumbnailIt’s easy to call the doctor when you’re sick. If you don’t feel well, getting help seems natural. But what about when you’re feeling fine?

Preventive care, such as routine health screenings, is key to staying healthy. Yet, numbers show that many of our patients are overdue for routine health screenings such as mammograms and colonoscopies, and those with chronic ailments like hypertension and diabetes don’t regularly see a doctor to help manage their condition.

“Medical care is often reactive rather than proactive,” says Trista Johnson, Ph.D., associate vice president of Clinical Services for Providence. “We want to be proactive in identifying at-risk patients and getting them in the door before they get sick so they avoid a costly emergency department visit or hospital stay.”

Closing the gap

Closing that gap in care and improving the overall health of our patients is what our medical groups are aiming to do through its chronic and preventive care outreach program.

Our care teams and providers have partnered to focus on improving seven key areas. For preventive care, the focus is on cervical cancer screening, breast cancer screening, colorectal cancer screening and pediatric vaccination. For chronic care, the focus is on diabetes management, blood pressure control, and statin use in patients with cardiovascular disease.

So far, results have been staggering.
  • Breast cancer screening: In 2014, breast cancer screening rates collectively throughout Providence ranked in the bottom 35 percent of the nation. This year, Providence leaped to near the top 25 percent in the nation (close to the 75th percentile).
  • Colon cancer screening rates jumped from the 75th from two years ago and nearing the 90th percentile today.
  • By the end of this year, Providence is predicted to meet six of its seven quality metrics – meeting goals for diabetes and blood pressure control management, and pushing our screening rates for colon cancer, breast, cervical and pediatric immunizations in the top 25 percent nationally. 

Tools for success

Patients are identified using Healthy Planet, an accountable care and population management system module in Epic. Healthy Planet combs through patient records to see when the last time a patient came in and what screenings or health maintenance is needed. Patients are then contacted via:

  • Mailed letters with scorecards – easy-to-read snapshots of a patient’s health, with target goals and action steps
  • Phone calls from local care teams to help schedule appointments, as well as automated telephone calls
  • Emails in MyChart
  • Text messages with important health reminders from their doctor

Dedicated care teams prepare the primary care team for the patient visit, minimizing work on providers by coordinating with their schedules, teeing up orders in Epic, and requesting outside records when needed.

We’ve also surfaced success stories – like the hard-to-reach patient who promptly visited his doctor upon receiving a text, or the patient who finally agreed to get a colonoscopy despite multiple refusals in the past, or the patient whose cancer would have gone undetected had she not done her screening at the request of her care team.

“By leveraging clinical data that reveal gaps in care – we’re able to reach out to our patients individually and arrange for the recommended follow up or treatments they need in order to keep them healthy,” says Warren Fein, M.D., Executive Medical Director, Primary Care, Swedish Medical Group.