What is the best way to mange Gap in Care of the patients?

Would we continue running our list of patient that have not been seen in a fiscal year? How often is it suggested to run these list/date of patients.

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Trushna, some organizations design their “gap in care” report showing all patients needing care interventions to be run as often as a daily. Organizations who stay on top of this process work the report all year long, generally assigning this work either to staff assigned to the panel or to centralized staff to make this outreach standard work. I have seen effective teams use team staff (front office, MAs, care navigators…) to contact patients about the care gaps for just their panel of patients leveraging their relationship with the patient. At Clinica in Colorado the two front office staff for each pod are responsible for contacting approximately 10 patients on their panel throughout their workday, Tuesday through Friday as standard work. This distribution of work, would allow them to reach out to 3,520 of their 3600 patient panel each year. Practices can sort the care report first by patient (so that in any contact, you can discuss all care that is due), then by diagnoses (to risk stratify outreach to patients at higher risk such as those with chronic diseases) and then by date due to address the most out of date care gaps first. I would love hear from other PHLN teams how they keep up with their population outreach work.

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Thank-you for the feedback. I had to read it again to strategized some ideas. Hope all is well with you.