Ensure Continuous Connection to Care
|
Avoiding “no shows”
|
2
|
14
|
51
|
33
|
Reconnecting patients who haven’t been seen in the clinic
|
2
|
16
|
39
|
43
|
Broad Education and Connection to Clinical Resources
|
Providing educational packets and brief counseling
|
-
|
6
|
43
|
51
|
Linking patients with need specific resources with those available within VA
|
2
|
4
|
51
|
43
|
Adherence Support
|
Following up on patients who don’t refill medications on time
|
-
|
8
|
43
|
49
|
Following up with patients who have just been prescribed medications that have complicated instructions or regimens
|
-
|
6
|
43
|
51
|
Promoting adherence by checking in with patients, identifying barriers
|
2
|
6
|
47
|
45
|
Identifying patients who need a review of their medication (e.g., titration/adjustment)
|
4
|
4
|
49
|
43
|
Target Patients with Special Needs |
Making a list of patients with specific lab values for follow-up
|
2
|
14
|
43
|
41
|
Making a list of patients who need specific tests ordered
|
2
|
21
|
41
|
37
|
Addressing co-morbidities (e.g., referring patients with severe depression to mental health; connecting diabetic patients to Diabetes Clinic) |
- |
6 |
51 |
43 |