How should practices communicate with established chronic care patients who require regular maintenance?

  • Develop a process to identify your established, chronic care patients and assign staff to review the list of patients to flag for necessary follow up.
    • Begin with a list of canceled, missed appointments.
    • Use tracking logs and/or EMR generated reports to identify lab studies and test that are due.
    • Review the EMR last visits to identify needed follow up.
  • Implement a triage process to assess patients to determine level of care (i.e. appointment, virtual check-in, telehealth, or referral) needed.
  • Implement a virtual check-in option to identify immediate needs, discuss necessity of a visit and/or recommend a referral. These touchpoints with patients allow providers to connect with patients, develop a treatment plan and are reimbursable (lower rate given short encounter).
  • Develop a Prescription Management Process to identify and prescribe medications for chronic care patients. The standardized process should include reconciling medications, verifying medications to routinely refill, and proactively contacting insurance companies for required pre-authorization approval.
  • Review current Diagnostic Test Management System to ensure staff are assigned to process tests needing a preauthorization, to schedule the patient for ordered tests, to follow-up outstanding results, and to ensure results are filed in the medical record for provider review.
  • Implement a Patient Screening System through patient portal or nurse triage line that allows certain subsets of patients (i.e. hypertensive, diabetic) to report home-monitored results (i.e. blood pressure, blood glucose). If the numbers are out of range based on patient’s documented history, medications could be adjusted or labs ordered without requiring the patient to schedule a visit.
  • Implement a check-in process with your high-risk patients. A scheduled phone call by the nurse or a telemedicine visit can ensure these patients receive the care needed.
  • If your practice provides care to children, then it is important to follow up with well-child visits and keeping immunizations on track.
    • If pediatric practices are limited in well child visits, then healthcare providers are encouraged to prioritize newborn care and vaccination of infants and young children (through 24 months of age) when possible.
  • Develop a standard letter template to send to patients via patient portal or mailing when patient fails to follow up.


News & Knowledge
All Curi recommendations are based on current CDC criteria at the time of publication. CDC guidance for SARS-CoV-2 infection may, or may not, be adopted by state and local health departments to respond to rapidly changing local circumstances. Providers should always check with their local health department to see if the CDC’s guidance on any given topic has been modified (particularly if more restrictive) from the CDC’s recommended guidelines. Follow this link https://www.cdc.gov/publichealthgateway/healthdirectories/index.html for contact information to your state/local health department. If local recommendations vary from those of the CDC, and you are unsure what recommendations to follow, then it is safer to follow the more restrictive guidelines/recommendations.