The quick start guide is a summary of the essential steps "at a glance" for this care management process (CMP). You can use it with a practice to give them an introduction to the tasks involved in implementing the CMP, or for busy clinicians and teams that already have completed much of the work, you can use it as the primary guide.

Systems for finding and reminding patients due for testing help practices prompt patients to take proactive steps to complete necessary testing and manage their health. Unlike recall systems which focus on notifying patients of abnormal results or missed appointments, reminders for tests due are about keeping patients on track with regular recommended preventive care and health maintenance tests. For individuals living with diabetes, this includes routine A1C testing, lipid testing, kidney function monitoring, annual comprehensive eye exams, and flu and covid vaccinations.

The term systematic refers to a structured, organized, and consistent approach to delivering reminders. It means the process of sending reminders is done in a planned, repeatable, and methodical way, often integrated into the practice’s workflow or technology systems. Systematic reminders are not ad-hoc or random, but are designed to ensure all patients are consistently reminded when their tests are due based on clinical data and established protocols—reducing the likelihood of gaps in care.

Systematic reminder systems can be fully automated, manual, or a hybrid process that combines both automation and manual tracking and reminder delivery. A fourth option, which may or may not be available to the practices you are working with, is outsourcing reminders to their ACO, IPA, or health plans.

Systematic patient reminders for tests was selected as a Blueprint CMP for improving diabetes care quality and outcomes based on the findings of the UNITED study. The study identified three out of 64 CMPs evaluated as contributing to the majority of the improved care quality and health outcomes for patients living with diabetes.

These high-impact CMPs were:

These processes were found to significantly enhance diabetes care quality and outcomes accounting for 47% of the total improvement in overall optimal diabetes care and 68% of the decrease in A1C levels.

As a practice facilitator or a primary care provider implementing or enhancing CMPs in a practice, knowing what “good” looks like can help you implement CMPs more effectively and efficiently, and can give you helpful ideas for making enhancements. Case examples are stroies that can give you ideas. Pearls are shorter real-world examples, submitted by practice facilitators and primary care providers as “helpful hints and tips” for implementing and using the CMP.

Click the link below to review examples and tips that have been submitted or to submit your own.

There are two pre-work activities you will need to complete with the practice before you and they get started. A first and essential first step in beginning work with a practice is always to engage practice leadership to confirm their buy-in, determine what they hope to accomplish by implementing (or enhancing) the care management process (CMP), and identify resources the practice has available to support work on the CMP.

The second piece of pre-work you will need to do is work with the champion and practice leadership to identify the CMP implementation team. Work with leadership to help them identified the person or persons who can make these decisions and carry out this work. This may be a special project team created by the practice for this project, the QI team, or in a small practice, even the office manager.

Regardless of who or which group is charged with working through these tasks to implement (or enhance) this CMP, ideally the group includes representatives from staff and clinicians who will be involved in and can provide input that can enhance the effectiveness of these changes.

These individuals are often overlooked, so work with the champion and leadership to make sure their voices and ideas are included in the conversations—either directly as a member of a team or through outreach to them for input. For example:

Click the worksheet below and use it to help the practice think about and select their project team.

Work with the practice to conduct a brief assessment of its “rent state” for sending test reminders for its patients living with diabetes.

Use the Current State Assessment Worksheet for this CMP below with the practice to assess the current state of their patient reminders or create your own tool.

The first step in implementing or enhancing any CMP is to clearly define the practice's goals for its adoption or improvements.

Work with the practice to determine their goals for this CMP for their patients living with diabetes.

Use the Goal Sheet below to record their goals and identify how they will determine when their goals have been met.

Work with the practice to assess the resources they have available for sending patient reminders for tests due. Automating as many of the steps in the reminder process as possible can make sending patient reminders more feasible for practices. Start with the practice's EHR and other related Health Information Technology (HIT) platforms, then move to other resources, and if none of those options are adequate, explore manual processes.

First, help the practice decide the approach it will use for selecting patient reminders of tests due to send. The American Diabetes Association recommends the following base set of patient reminders for improving outcomes for patients living with T2D.

Ask the practice if they would like to start with the ADA's basic set of patient reminders or use another set of criteria. If they would like to review other criteria, walk through the options below with the practice. Other options include:

Next, work with the practice to use these criteria to select the tests they want to implement patient reminders for, and develop the initial design for each. They will need to:

Use the Design Worksheet below to help the practice define these elements of their patient reminders.

Structured data is required in order to generate automated clinical reminders at visit and is also important to manual workflows if the practice is not using its EHR for reminders.

As a next step, work with the practice to evaluate how and where the practice documents the services that will be used to trigger the patient reminders such as comprehensive annual eye exams and foot exams.

If any of these data are captured in free text or recorded in different locations by different providers and staff, these must be revised in order to support patient reminder generation.

Work with the practice to evaluate the type and location of the data that it will use to generate the reminders and develop a plan for ensuring key data are available in structured format and in a consistent single location in the patient record.

You may need to engage the vendor during this process if the practice does not currently have structured data fields to capture data points needed for the reminders.

The completeness and consistency in documentation of key variables used to generate patient reminders is key to their accuracy and ultimate usefulness.

One side note, as AI becomes more available in health IT products, the ability of these systems to automatically capture and translate free text into structured data will increase. Check to see if these capabilities exist for the HIT systems used by the practice – and confirm their accuracy. This AI based functionality eventually may be a resource for you and the practice at this step.

Use the worksheet below to assess available structured data.

Next work with the practice to help them assess their current intake and patient information collection and identify any gaps in information collection that need to be addressed before going live with the reminder system.

Have the practice review the intake information for patients to assure it includes:

These data will need to be available in the EHR or third-party platform for use in generating automated reminders that send messages based on patient communication preference.

Patients experiencing social health barriers, such as financial distress or housing insecurity, may have frequent address and phone number changes and intermittent phone service which can affect their ability to receive reminders and impact health equity. The practice will need to pay special attention to any groups experiencing these social health factors.

Use the worksheet below to help the practice assess their current intake forms and process, and identify any additions needed.

Whether the practice is using an automated reminder system from their EHR or related vendor, or implementing a manual reminder system, they will need to decide which modes of communication they want to use for the reminders.

Work with the practice to ensure the reminders are HIPAA compliant. In addition to confirming the EHR system or third-party vendor use appropriate encryption and privacy protection processes, the practice will need to ensure their own processes and messages are HIPAA compliant.

Use the checklist below to help the practice assess the alignment of its new process with HIPAA requirements.

Next, work with the practice to define the workflow(s) for generating, monitoring and responding to the reminders.

Begin by creating a high-level map of the entire process.

Then create detailed process maps for each distinct element of the patient reminder process. Common workflows associated with reminders include:

To train a practice on process or workflow mapping you can use this module from the U.S. Agency for Healthcare Research and Quality (AHRQ): https://www.ahrq.gov/downloads/ncepcr/pf-modules/process-mapping/story.html

Use the Patient Reminders Roles and Workflows Worksheet to help the practice identify key roles and workflows for the new reminders.

Use the model for improvement and plan-do-study-act cycles (PDSA), or a similar process, to conduct small tests of different elements of the reminder system. Study and refine the processes based on outcomes.

Consider testing one reminder with a small number of patients with tests due and evaluating the process, refining, and then expanding to a few more patients until the process is working well.

Examples of metrics a practice might track in a series of PDSA cycles include:

Use the PDSA worksheet here to help the practice design and document their PDSA cycles

If it would be helpful to train the practice on PDSAs before you begin this task you can use this resource at U.S. AHRQ: https://www.ahrq.gov/downloads/ncepcr/pf-modules/model-pdsa/story.html

You can also gather feedback from staff on the implementation using a survey format. Use the form below for this purpose or work with the practice to create their own.

Educating patients about the purpose of patient reminders is crucial for the success of a reminder system and for patients to have a positive experience with the reminder process. Before the practice implements the reminders, work with the practice to develop scripts, posters, flyers, and other methods of educating patients on the reminder process. Include information about:

This education promotes patient engagement and increases their comfort level with the technology, leading to higher acceptance and usage rates. Use the worksheet below to help the practice design a patient education campaign on the reminders.

Work with the practice to develop its patient education program. Use the worksheet below to guide them through this process.

Use the worksheet below to help the practice design a patient education campaign on the reminders.