Table 2.

Final panel management toolkit¹

Care gap	Target population	Strategy
Ensure continuous connection to care	• Smoking or hypertensive patients with a missed appointment	Call patients to reschedule appointment, troubleshoot barriers to attending clinic and offer reminders about upcoming visits
	• Smoking or hypertensive patients with a history of no shows or long gaps between visits
	• Smoking or hypertensive patients with frequent visits to the ER/UC
	• Smoking or hypertensive patients not following up with assigned team	Outreach to determine patient status. Remove patients who have moved, are receiving care elsewhere or who have died from panel. Transfer patients to a more appropriate care team such as home based or mental health based primary care
	• Hypertensive patients with no visits in 6 months or more	Call or provide a list to team clerk to setup a visit
	• Smokers with no PCP visits in a year or more
	• Hypertensive patients with upcoming blood pressure check or PCP visit	Call or provide list to team clerk to remind patients about visit and need to take medications as usual to ensure accurate reading, enquire about questions or concerns for visit
Broad education and connection to clinic resources	• All hypertensive patients	Mail educational resources about hypertension, managing blood pressure through diet and exercise and clinic resources
	• All smokers	Mail educational resources including benefits of quitting, tips and clinic resources
Targeted behavior change counseling	• Hypertensive patients with unmeasured blood pressure from last visit	Review records and identify those to all or refer to RNCM to setup a blood pressure check visit
	• Hypertensive patients with systolic blood pressure greater than 140 or diastolic blood pressure greater than 90
	• Current smokers with evidence of interest in quitting	Mail educational packet with more specific tips for quitting and a list of resources available
	• Patients who received an NRT prescription within the last month	Call to see if patient has used NRT and inquire about side effects and any questions about use. Use motivational interviewing or brief action planning technique to troubleshoot barriers and make plan going forward
	• Current smokers with a history of refusing cessation counseling or treatment	Mail educational information about cutting back and how to access resources including NRTs, telephone support and in-person group
	• Smokers who have quit within the last 6 months	Review records and call patients to check in on their status (smoking, quit or cut back) and motivational interviewing or brief action planning to troubleshoot barriers or make a plan
	• Smokers previously counseled or actively quitting	Follow-up call to check on status, offer light motivational interviewing to troubleshoot problems and referral to appropriate resources
	• Smoking patients who have not been counseled on cessation in that last year	Call patients to check in on their status (smoking, quit or cut back) and motivational interviewing or referral to resources as needed
	• Patients with uncontrolled hypertension who smoke
Adherence support	• Hypertensive patients with poly-pharmacy (e.g. 10+ unique active prescriptions)	Refer to team pharmacist for medication management
	• Hypertensive patients with expired or unfilled prescriptions	Refer to pharmacy line, team pharmacist or PCP as appropriate
	• Hypertensive patients who have difficulties with their prescription	Review history and refer to team pharmacist, RNCM or PCP as appropriate
	• Smoking patients with multiple, inconsistently used NRT prescriptions	Call to see if patient has used NRT; inquire about side effects and any questions about use. Use motivational interviewing or brief action planning technique to troubleshoot barriers and make plan going forward
	• Smoking patients who need a new, renewed or different NRT prescription	Refer to team pharmacist or PCP to update the prescription
Patients with special needs	• Hypertensive patients with diabetes and a systolic blood pressure greater than 130 or diastolic greater than 80	Call patients or refer to RNCM to setup BP check visit. Make a referral to diabetes management group or team nutritionist as appropriate
	• Hypertensive patients with a BMI of 25 or greater	Refer patients to team nutritionist, MOVE program or offer light motivational interviewing on behavior change for diet and exercise
	• Hypertensive patients with multiple chronic illnesses	Refer patients to Telehealth program for more intensive home based management of hypertension and chronic conditions
	• Hypertensive patients with persistently high blood pressure readings
	• Hypertensive patients with high blood and difficulty keeping clinic visits
	• Hypertensive patients with co-morbid CHF or CRF	Refer to CHF or CRF management groups
	• Smokers with concerns about weight gain when quitting	Referral to team nutritionist for advice and counseling

¹Acronyms used in the table: PCP Primary Care Provider, NRT Nicotine Replacement Therapy, CHF Congestive Heart Failure, CRF Chronic Renal Failure, RNCM RN Care Manager, MOVE diet and exercise program offered by the VA.