Technology tools are a key part of the care coordination Vanguard Medical Group provides to improve outcomes for diabetic patients.
The 20-provider primary care practice in New Jersey gained designation as a Patient Centered Medical Home and joined a diabetes management pilot project in 2010 when a regional insurer began compensating practices for care coordination and patient-engagement efforts, according to a post at PhysBizTech by Janet Duni, the system's director of care coordination.
The system focuses on creating an action plan for each patient and working with each one to achieve goals, according to Duni. Vanguard, she says, uses technology to identify high-risk patients, aggregate and track patient activity and track outreach to them through a database and EHR, which makes extensive use of notes from a team of caregivers.
What's more, she says, its website, online decision aids and other resources help patients to understand the importance of such as daily blood sugar testing, reading food labels and medication adherence.
In 2012, Vanguard scored in the 90th percentile on nine of 10 quality metrics for a subset of more than 6,000 commercially insured patients. They included metrics affecting diabetics such as blood pressure, HbA1c and microalbumin. The system also reduced hospital readmissions by 25 percent compared to its peer practices. According to Duni, its focus on self-management has reduced costs and improved patient satisfaction.
As physicians look for ways to better engage patients in Meaningful Use Stage 2, many see chronic disease management and routine follow-up as prime areas to do so. Patient portals have been advocated as an effective way to test results, patient education and for patients to ask questions.
The National eHealth Collaborative, in November, proposed a framework based on five pillars gleaned from those who have found success with engagement. That framework uses a phased approach.
"Given where health IT is as an industry--it's still so new--I think it's appropriate that people are thinking about consumer engagement in lots of different ways," NeHC CEO Kate Berry told FierceHealthcare.
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