Population health management equips physicians and their teams with techniques to help monitor their patients. This allows health care teams to provide necessary preventive and chronic care to all patients, regardless of the frequency of their visits. Through the creation of population reports or registries, an independent practice in Louisiana saw a 77 percent increase in their ability to identify care gaps.

Shreveport Internal Medicine (SIM)—in collaboration with QualityImpact and the Transforming Clinical Practice Initiative (TCPI), which assists clinicians in achieving large-scale health care transformation— identified and addressed focus areas to improve quality of patient care. Two areas involved identifying the risk level of each patient and providing appropriate care, and using population reports or registries to identify care gaps and ways to reduce them.

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“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 SIM. “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.”

Identifying care gaps—which can include items such as overdue eye exams or uncontrolled blood pressure—“was easy, but closing and reducing the gaps is still a problem,” 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.”

Need identified; nurse helps follow up

At SIM, the team used an outside product to identify care gaps. This registry provides an overall risk-stratification of the entire patient population, gives a breakdown of how many have each chronic condition, when their next appointment is, what their care gaps are, what labs are due and when they had their immunizations—a snapshot of key patient information.

SIM has achieved a 97 percent increase in improved risk-level identification and a 77 percent increase in care-gap identification.

Physicians receive a weekly list of patients who are coming in with care gaps identified. The information is provided on paper so that physicians can have it in their hands when they walk in the room and don’t have to manually log into the outside system.

“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,” said Brown. “The nurse will schedule those without the doctor even having to get involved in it.”

With the overall risk level identified, Brown and her team targeted areas for improvement. For example, SIM identified a need to focus on hypertension last year. The practice wanted to reduce the overall high blood pressure rates “just a little bit.” As a result, the BP 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,” said Brown. “That is what we go for here—those small little changes that are going to affect our population.”

AMA’s is an open-access platform featuring more than 50 modules that offer actionable, expert-driven strategies and insights supported by practical resources and tools. Based on best practices from the field, STEPS Forward modules empower practices to identify areas or opportunities for improvement, set meaningful and achievable goals, and implement transformative changes designed to increase operational efficiencies, elevate clinical team engagement, and improve patient care.

Several STEPS Forward™ modules have been developed from the generous grant funding of the federal Transforming Clinical Practices Initiative (TCPI), an effort designed to help clinicians achieve large-scale health transformation through TCPI’s Practice Transformation Networks.

The AMA, in collaboration with TCPI, is providing technical assistance and peer-level support by way of STEPS Forward resources to enrolled practices. The AMA is also engaging the national physician community in health care transformation through network projects, change packages, success stories and training modules.


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