Outreach and Screening

Proactive outreach and preventative screening support continuity of care for patients at their PMH.

How to engage

Enhanced and Comprehensive members interested in developing a patient screening goal to support their patients and medical homes should contact their Health Information Coordinator to set up a PMH team meeting.

Program details

The PMH team supports members in identifying patient groups that would benefit from proactive screening or chronic disease management.

Health Information Coordinators use EMR data to identify patient groups for quality improvement projects, identify screening maneuvers, and recommend screening projects for chronic disease management.

Patient Care Coordinators are able to coordinate patient care through outreach for appointment scheduling, updating charts, and gathering hospital transfer information.

PMH teams monitor progress and keep the physician informed.

Proactive outreach and screening initiatives ensure patients at-risk of developing health conditions are identified and treated early. This early identification can assist in preventing negative health outcomes for patients.