Date of Publication


Project Team

Ellen Watson, MSN ; Jeanine Carr, PhD, RN


Purpose. The way that patient care is being delivered is evolving. One way in which this is happening is through patient centered medical homes (PCMH). PCMH represent a model of care that is accountable for meeting a patient’s care needs, including prevention and wellness, acute care and chronic care. To obtain status as a recognized PCMH, practices must fulfill specific quality care initiatives including patient outreach. Another way in which patient care is changing is through MACRA. This government initiative changes the way that practices are reimbursed for their services from fee-for-service to outcomes based measurements. Practices are now responsible for reporting on 4 different measures, with this project focusing on the quality improvement and meaningful use. This protocol is meant to fulfill these requirements. This project outlines specific guidelines for 12 different patient outreach topics including: pap smears, hypertension, colorectal cancer screening, pneumonia vaccinations, depression screening, smoking cessation in patients with COPD, hepatitis vaccination, Tdap vaccination, INR in patients on coumadin, mammograms, HgA1C, and influenza vaccination. These guidelines determine the criteria for creating lists of patients via the electronic health record (EHR), that need to be contacted for each of the 12 topics.

Methods. It was planned to use reporting tools and data mining capabilities from the EHR in use at the clinic to develop lists of patients who met specific criteria pertaining to each topic and its associated guideline and to contact patients electronically via MyHealthOnline (a profile used to securely communicate from provider to patient and vice versa). The goal was to encourage them to contact the office to make an appointment to address that specific health maintenance topic. Outcome measures were determined to be the number of patients who needed to perform each of these activities at the beginning of implementation, versus those who have them completed after patient outreach within a 4-month period.

Results. Electronic communication was not feasible as many of the patients at the practice were not signed up for MyHealthOnline. Instead, a smaller sample size of 64 patients was contacted across 4 selected health maintenance topics: colonoscopies, pneumococcal vaccines, Hemoglobin A1C’s >8%, and hypertension. Twenty patients were contacted about colonoscopies, 6 for pneumococcal vaccines, 18 for HgbA1C >8% and 20 for hypertension. Of those contacted, 34 answered their phone and 30 were left voicemails – 2 of whom immediately called back. Average time spent per phone call was 2 minutes, with outliers of 17 seconds and 20 minutes. Currently, 2 months have passed since the intervention was implemented. Outcomes will be calculated once 4 months have passed since implementation.

Conclusion. Reliable methods of communication between care providers and patients are vital to patient outreach. Organization of clinical data and protocols for doing such activities are vital for ease of submission of required data for clinics wishing to maintain their status as a patient centered medical home and to achieve maximum reimbursement from Medicare/Medicaid. Patient outreach has other benefits including presenting a unique opportunity for education and motivation.

Document Type


Included in

Nursing Commons