Practice Systems Questions for HCH Certification That Address Diabetes Care, in 5 Domains
| Access: continuous access and communications with patients and family |
| 1. “Advanced access” or “open access” visits (scheduling that encourages your office staff to offer same-day appointments to virtually all patients who want to be seen) |
| 2. Scheduling system to encourage patients to see their personal physician |
| 3. Follow-up when diabetes patients have missed important appointments |
| 4. System to identify and remind patients with diabetes who are due for a follow-up visit |
| 5. System to identify and remind patients with diabetes who are due for testing |
| 6. System to identify and remind patients with diabetes who are due for a prescription renewal |
| 7. System to identify and notify patients who are due for age-appropriate preventive services |
| 8. Routine use of secure e-mail to support self-management for patients and their families |
| 9. Routine use of an interactive website to support self-management for patients and their families |
| 10. Routine use and data exchange with patients who have access to their own electronic health record |
| Registry: an electronically searchable registry to identify care gaps and manage services |
| 1. A registry for diabetes (list of patients along with associated data) |
| 2. Guideline-based reminders for services the diabetic patient should receive that appear when seeing the patient |
| 3. Checklists of tests or interventions that are needed for prevention or monitoring of diabetes |
| 4. System to provide alerts about important abnormal test results to the doctors at the time they are received |
| Coordination of care: care coordination for patient- and family-centered care |
| 1. Nurse managers to coordinate care for patients with especially complicated conditions |
| 2. System for tracking laboratory or radiology tests until results are available to the clinician |
| 3. System to track critical referrals until the consultation report returns to the practice |
| 4. Designated primary care teams, defined as a physician and other staff that collaborate in the care of a defined group of patients |
| 5. Previsit planning routinely provided to patients with diabetes by someone other than a physician, PA, or NP |
| 6. After-visit follow-up routinely provided to patients with diabetes by someone other than a physician, PA, or NP |
| 7. Provide or refer patient with diabetes to formal support programs to assist in self-management |
| 8. System to promptly learn when one of your patients has been discharged from a hospital |
| 9. System in place to manage recently discharged patients |
| Care plans: care plans that involve patients with chronic or complex conditions |
| 1. Routine development of individualized self-management plans with goals for patients with diabetes |
| 2. Routine provision and review of self-monitoring instructions for patients with diabetes |
| 3. Provide written materials that explain to the patient the recommended medical care guidelines for diabetes |
| 4. Systems to encourage diabetes patient self-management |
| 5. A systematic process to conduct shared decision making with patients |
| 6. Develop care plans with patients to manage care for diabetes |
| Quality improvement: continuous improvement in patient satisfaction, outcomes, cost-effectiveness |
| 1. A formal process for measuring performance for individual physicians or for the practice site |
| 2. Provision of data to individual physicians on the quality of their care for patients with specific chronic conditions |
| 3. Conduct or participate in formal quality improvement activities |
HCH = health care home; NP = nurse practitioner; PA = physician assistant.
Note: For each system, practice leaders were asked whether their practice had any such system in place.