RT Journal Article
SR Electronic
T1 A Clinical Interaction Model with Tiered-Based Outreach via Mobile Notification Increases follow up for Chronic Conditions
JF The Annals of Family Medicine
JO Ann Fam Med
FD American Academy of Family Physicians
SP 4093
DO 10.1370/afm.21.s1.4093
VO 21
IS Supplement 1
A1 Burr, Jeffrey
A1 Lesser, Lenard
A1 Temple, Jennifer
A1 Datta, Esha
YR 2023
UL http://www.annfammed.org/content/21/Supplement_1/4093.abstract
AB CONTEXT: Ensuring patients with chronic conditions achieve regular follow up is a challenge in primary care. While disease-based algorithms provide guidance for care, many patients need more individualized care plan recommendations that are delivered through mobile applications. OBJECTIVE: Develop a tiered-based outreach system that provides follow-up recommendations for patients in primary care. We tested whether these recommendations, delivered through a mobile-app notification system, increased patient follow up.STUDY DESIGN: We developed an algorithm for assigning patients to different primary health care need tiers based on the Charlson Comorbidity Index (CCI) and the presence of a subset of chronic conditions described by the Medicare Chronic Conditions Data Warehouse. Medical Directors assigned a recommended frequency of primary care visits for each of four tiers. SETTING/POPULATION: Primary care patients of a national membership-based primary care delivery system, operating in several metropolitan locations in the US.INTERVENTION: We ran two randomized experiments to assess whether patients receiving a care recommendation for follow-up via a mobile application were more likely to follow-up than those who did not receive a recommendation. The mobile application is linked to our EHR.OUTCOME MEASURE: Percentage of patients booking a primary care appointment.RESULTS: The outreach system classified patients as Tier 1 (CCI=0, no chronic conditions), Tier 2 (CCI=0, at least one chronic condition), Tier 3 (CCI=1 or 2), Tier 4 (CCI>2). In the 8000 patients randomized in Tiers 2 and 3, 17% in the intervention group booked a visit, compared to 9.9% in the control (p<0.01). In the 2404 patients randomized in Tier 4, 17% in the intervention group booked a visit, compared to 8.2% in the control (p<0.01).CONCLUSIONS: A tiered-based outreach system based on clinical criteria and delivered via push notifications increases patient engagement for chronic conditions. Future research can look at the clinical outcomes of these outreach methods.