ReminderPro is an automatic system that is fed a database of patients who have missed their appointments and follows-up with an automated call to their contact number. Can be supplemented manually with human effort and physically entered into EMR.
-Quarterly report is created that extracts the data from the EMR and defines a set of "lost to follow up" patients (not seen in past 9 months) and a set of "poor immunological state" patients (CD4 t-Cell count <200, or HIV mRNA >100,000 copies/mL. These two lists are then distributed to peer navigators who work with Care Coordination Program. these "Peers" are trained HIV+ individuals who provide friendly inpatient visits, education, orientation, and counseling. they follow up with phone calls and letters as well. If navigators get through, they reschedule appt. with patient. All Peer activity is logged and monitored/reviewed by Program Coordinator.
"No Patient left behind" gives each provider a list of patients who are out of care. they are then responsible for making outreach attempts for 30 days for medically unstable patients and 90 days for medically stable patients. Outcomes are documented in database that is regularly monitored.
EMR has section to remind provider of preferred method of communication with each individual patient.