Population Health
Bigger Picture
In-between visits
 Master of the office visit
 What becomes of our patients between?
 Sometimes we want them to do stuff
 What if they don’t do it?
 We are here to remind them
Lab, Rad, Colonoscopy…Oh My!
 Acute Disease -Diagnosis
 Chronic Disease -Managing
 Screening for health issues –Also important
What do we have to do?
 Largest contingent of provider staff
 Monitor the staff buckets for overdue testing
 Use the tools – Athena Communicator
 Use judgment talk to their provider
Dos and Don’ts
 Do – let the patient know we care about them
 Don’t –Present the overdue item as a chore
 Do – Use your established rapport
 Don’t – Act frustrated
 Do – Have knowledge to share (why do this thing)
 Don’t – Be pushy (It is their choice)
Why do this thing?
 Acute Conditions
 Follow up testing
 New concerns
 Direct communication from Provider
 Chronic Disease Management
 Conditions change over time need to keep track
 Medications can have effects on organ systems
 Due diligence to keep track of how patient is doing
 Screening
 Scary, uncomfortable, inconvenient
 Prevention and early intervention worth a ‘pound of cure’
Elective and Specialist Referrals
 Physical Therapy
 Pain control
 Referrals
 Consult/Evaluation/Shared management
 Board Certified Sub-specialists