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CP26 - A Model for Patient Outreach to Address Outstanding Preventive and Maintenance Health Care During the COVID-19 Pandemic

‐ Aug 18, 2021 11:25pm

CP26 - A Model for Patient Outreach to Address Outstanding Preventive and Maintenance Health Care During the COVID-19 Pandemic

Poster Type: Innovation

Category: Expanding Access to Care and Other Services

Issue or Challenge: The COVID-19 pandemic limited access to routine healthcare including cancer screenings, blood pressure checks, diabetes exams, and others. Of 8 metrics for preventive and maintenance healthcare tracked by Denver Health for Lowry Family Health Center, decreased scores were noted across the board from January 2020 to May 2020. The challenge was to enhance access to these necessary medical services for an underserved population and to produce better health outcomes by re-engaging patients in their preventive and maintenance healthcare in safe ways during the pandemic.

Description of Innovation: A patient outreach strategy was developed to address patient care gaps based on 8 metrics routinely tracked by Denver Health. These 8 metrics were considered suitable for outreach because they involved completion of a lab or screening test or scheduling an in-person visit with a provider. The metrics address diabetes (A1c and nephropathy), hypertension, breast/colon/cervical cancer screening, pediatric vaccinations, and asthma. A calendar was developed which listed the metric of focus for each week and included clickable links to standard work. The outreaches were done by medical assistants and included accessing a report for overdue health maintenance in the electric record, placing orders for labs or screening exams, and calling or sending a letter to patients with instructions for scheduling a visit or obtaining tests. Progress was evaluated using a tracking function in the electronic record for recent outreaches as well as change in the clinic’s success rates on the metrics over time.

Impact or Result: 752 individual outreaches were completed between June and December 2020. Rates of success for some metrics improved over that period including diabetic nephropathy testing (+1.2%), cervical cancer screening (+1.4%), and asthma control (+2.8%). However, rates of success decreased in some metrics including diabetic A1c control (-2.7%), breast cancer screening (-1.3%), hypertension control (-0.9%), pediatric vaccinations (-0.8%), and colorectal cancer screening (-0.5%).

Replicating this Innovation: The outreach calendar model would easily replicate. After choosing the healthcare gaps to be addressed, one would need a reliable way to determine those patients that require outreach and a way to track who has been outreached and when.


Raeanna Simcoe, MD, Senior Instructor, Denver Health and Hospital Authority

Jessica Bull, MD, Assistant Professor, Denver Health and Hospital Authority

Zita Fenner, RN, Nurse Program Manager, Denver Health and Hospital Authority