We’ve begun to create an Outreach Dashboard, which tracks the patients who qualify in the Gap Measure. We then have our team outreach worker follow-up with the patients to see if they could bring them back into care or at least understand and account for why they are out of care.
We are also developing a peer-to-peer program that employs patients as ‘mentors’/ ‘coaches’ to new and struggling patients and support groups that allow patients to gain perspective on their respective barriers. All three projects are relatively new and have yet to show any noticeable results.
Barriers/Challenges: There are two barriers that standout: 1) identifying and contacting patients who have very little information listed in their medical records and 2) retaining patients who are adherent and self-sufficient. The latter problem primarily hinges on communicating to patients the necessity of medical visits despite them being self-sufficient. We are hoping to better our ‘culture’ as a program and organization.