Detecting and Treating Chronic Disease
Screening, testing and referral (STR) strategies can be used to effectively prevent, detect and treat chronic disease. However, most patients are not identified as high risk in the early stages. Utilizing screening, testing and referral strategies can help identify at-risk patients in need of additional healthcare to help monitor their conditions. Referrals from healthcare providers can be an important predictor of enrollment in evidence-based prevention and management programs such as the National Diabetes Prevention Program (National DPP) and Diabetes Self-Management Education and Support (DSMES) program.
Implementing screening, testing and referral strategies at your healthcare facility:
- Save time during office visits
- Decrease costs and secures savings
- Improve health outcomes
- Increase quality measures
- Decrease patient population risk for chronic diseases
Effective Screening and Testing
Healthcare providers can identify target populations by risk, level of engagement or target conditions, for example:
- Those with elevated blood pressure and other major risk factors (such as obesity, cardiovascular disease, tobacco use, or socio-demographic risk factors that, if identified and counseled, may assist in reducing the risk of disease)
- Those with potential prediabetes or diagnosed diabetes who have not had a visit in more than 1 year
- Those with potential prediabetes or diagnosed diabetes with uncontrolled blood sugars at two separate medical visits during a defined period
Utilizing electronic health records (EHRs) can support healthcare providers to screen for, test and refer patients who meet criteria. Use EHRs to:
- Adopt algorithm(s)
- Convert algorithm into data extraction report (for pulling patient lists); and/or
- Create an EHR Alert/Flag (for use at point-of-care)
- Develop process for ongoing data extraction and pre-visit identification of patients who meet criteria
When using screening, testing and referral strategies, implement best practices like team huddles and panel management for detecting, treating and partnering with patients to prevent the progression of their chronic disease(s). This is a proactive way to ensure that everyone assigned to a clinic is up to date on basic preventive care – like screenings or immunizations – and that the patient receive extra help if they have lab numbers that are high.
Panel management can be used as a proactive mechanism where clinical staff members identify at-risk patients and notify them about healthcare plans they didn’t know was needed to prevent or manage their conditions. Outreach panel management can be defined as clinical staff members who reach out through phone or letter to a patient who does not have an upcoming appointment or has not been seen at the clinic recently.
Clinical staff members can also notify patients about healthcare gaps while they are in the clinic receiving care for other issues in a process known as in reach panel management.
Bi-directional referral systems consider the information going from the healthcare system to the referred community program or resource and help to close the healthcare gap by providing real-time updates to the referring healthcare provider on the patient’s status. Implementing a defined referral process will help the patient successfully access the referred lifestyle change program. Creating a referral system with community resources can make it easier for community organizations to loop back around to the referring healthcare provider, thus forming a community-clinical linkage.
Find a Lifestyle Change Program Near You!
Use our search tool to find community resources and programs you can refer your at-risk patients to and help them prevent or manage their chronic conditions.