From: Effective population management practices in diabetes care - an observational study
Practice | Definition | Items |
---|---|---|
Health System Organization | Â | Â |
   Financial Incentives | Amount of physician salary at risk, subject to assessment of performance on population care quality indicators. | 4 |
   Provider Feedback | Reports to providers about performance and degree of blinding to all providers. | 40 |
Self-Management Support | Â | Â |
   Patient Action Plans | Individual goal setting supported by action plans including needs assessment, personalization, and regular clinician review. | 4 |
   Patient Education | Education and support services based on self-management principles in a variety of formats. | 35 |
Delivery System Design | Â | Â |
   Defined Care Path | An explicit protocol or model guides population care. | 4 |
   Risk Stratification | Use of an algorithm to stratify patients by risk level and determine the level of proactive care provided. | 4 |
   Outreach/Follow-Up | Proactive, planned care. | 19 |
   Inreach | Customized reminders for patients of needed care whenever they present for service. | 5 |
   Care Coordination | Processes and structures supporting effective patient care handoffs, including explicit protocols and accountabilities. | 6 |
   Cultural Competence | Care tailored to the needs of major racial, ethnic, and cultural groups. | 15 |
   Team Accountability | Accountability for patient care vested in care teams rather than individuals. | 1 |
Decision Support | Â | Â |
   Guideline Distribution and Training | Distribution of evidence-based guidelines and clinician training on guideline content, including electronic availability, continuing medical education, and inter-provider communications. | 5 |
   Provider Alerts | Customized, context-sensitive paper-based or electronic alerts reminding providers of appropriate care for individual patients and groups of patients. | 28 |
Clinical Information Systems | Â | Â |
   Registry | Completeness and quality of a registry or database of key indicators for all patients with diabetes. | 72 |
   Electronic Medical Record | Availability and comprehensiveness of clinical data during patient visits. | 36 |