miércoles, 17 de enero de 2018

An Innovative Community-based Model for Improving Preventive Care in Rural Counties. - PubMed - NCBI

An Innovative Community-based Model for Improving Preventive Care in Rural Counties. - PubMed - NCBI

AHRQ News Now

Study Finds Wellness Coordinators Improve Rural Preventive Health Care

Preventive health services among Oklahoma residents in a rural county increased significantly when wellness coordinators working with primary care practices, the county health department, the county hospital and a health information exchange organization contacted county residents to help arrange for them to receive evidence-based preventive services, according to an AHRQ-funded study. The coordinators used a wellness registry developed from electronic medical records to flag gaps in patients’ preventive care, track outreach efforts and document the delivery of preventive services. Among about 5,000 patients who received calls from wellness coordinators, the delivery of 10 selected preventive services improved about 35 percent. Access the abstract of the study, which was published in the Journal of the American Board of Family Medicine.

 2017 Sep-Oct;30(5):583-591. doi: 10.3122/jabfm.2017.05.170035.

An Innovative Community-based Model for Improving Preventive Care in Rural Counties.



This quasi-experimental pilot study aimed to implement and evaluate a sustainable, rural community-based patient outreach model for preventive care provided through primary care practices (PCPs) located in a rural county in Oklahoma. A Wellness Coordinator (WC) working with PCPs, the county health department, the county hospital, and a health information exchange (HIE) organization helped county residents receive evidence-based preventive services.


The WC used a community wellness registry connected to electronic medical records via HIE and called patients at the county level based on PCP-prioritized and tailored protocols. The registry flagged patient-level preventive care gaps, tracked outreach efforts, and documented the delivery of preventive services throughout the community. Return on investment (ROI) for prioritized preventive services was estimated in participating organizations.


Six of the 7 PCPs in the county expressed interest in the project. Three of these practices fully implemented the 1-year outreach program starting in mid 2015. The regional HIE supplied periodic data updates for 9138 county residents to help the coordinators address care gaps using the community registry. A total of 5034 outreach calls were made by the WC in the first year and 7776 prioritized recommendations were offered when care gaps were detected. Of the 5034 distinct patients who received a call, 1146 (22%) were up to date on all prioritized services, whereas 3888 (78%) were due for at least 1 of the selected services. Health care organizations in the county significantly improved the delivery of selected preventive services (mean increase, 35% across 10 services; P = .004; range, 3% to 215%) and realized a mean ROI of 80% for these services (range, 32% to 122%). The health system that employed the WC earned an estimated revenue of $52,000 realizing a 40% ROI for the coordinator position.


Although more research is needed, our pilot study suggests that it may be feasible and cost effective to implement an innovative, county-level patient outreach program for improving preventive care in rural settings.


Community Health; Outreach; Prevention; Primary Care; Wellness Coordinatorh


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