Population reports help Louisiana practice find, close care gaps

After creating population reports to help monitor patients, a Louisiana-based independent practice saw a 77 percent increase in its ability to identify care gaps, according to a blog post on the AMA Wire.

Population health management tools allow providers to give preventive and chronic care to all patients, regardless of how often they visit the practice.

Shreveport (La.) Internal Medicine collaborated with Quality Impact and the Transforming Clinical Practice Initiative, which assists clinicians with large-scale healthcare transformation, to identify and address areas to improve care quality.

Two areas involved determining risk levels for each patient and providing appropriate care, and using population registries to find care gaps and strategies to reduce them.

"The care gaps we encountered were really around patients with diabetes and IVD [ischemic vascular disease]," said Rachael Brown, a health information technologist and quality manager at Shreveport Internal Medicine. "In Louisiana we like to eat, and we have a lot of patients who are obese or who have diabetes — about 55 percent of our population."

Care gaps, including overdue eye exams or uncontrolled blood pressure, were easy to find, but reducing and closing the gaps remains challenging, Ms. Brown said.

"A lot of patients just don't go to their eye exams. However, we hit them every time they come in with whatever the care gap action item may be," she said, trying "every avenue and potential way to get it closed for them."

The registry at Shreveport Internal Medicine provides an overall risk stratification of the entire patient population, provides a breakdown of how many patients have each chronic condition, when their next appointment is, what their care gaps are, what labs they need and when they received immunizations.

As a result, Shreveport Internal Medicine has achieved a 97 percent increase in improved risk-level identification and a 77 percent increase in care-gap identification.

The practice's physicians receive a list each week of patients coming in with identified care gaps. Physicians receive a paper copy of the information so they can have it when they walk into the exam room.

"I try to identify at least one so that when the doctor is in the room with the patient or the nurse, they can go ahead and address those open care gaps, like something as simple as getting an eye exam done," Ms. Brown said. "The nurse will schedule those without the doctor even having to get involved."

The Shreveport Internal Medicine team targeted areas for improvement, including a need to focus on hypertension in 2017. The practice's blood pressure control rate improved to about 80 percent.

"If I have a doctor that is focused on blood pressure at every visit and if he has a key indicator when he goes in that room that the blood pressure is elevated today and he doesn't have to dig for that information, then that is improvement in care," Ms. Brown said. "That is what we go for here — those small little changes that are going to affect our population."

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