Follow-up Form Letter??? :)

SHGR, MSN, RN, CNS · Apr 12, 2012

Hi! I am an RN/CDE too! Yes, we have a form letter. It came as part of our EMR software package and ... it's terrible. LOL

Our clinic does have a process in place for this. We make patient registries, by provider, of all our patients with diabetes, and when their last a1c's were, when their last visit was, BP, whether they have either had a microalbumin within the rolling calendar year, or see nephro, LDL within year.

These registries are distributed by medical assistant (so, for instance, Mary MA works full time, so she gets three docs...Keisha MA works 0.6, so she gets two, that type of thing) and then each MA is responsible for "working the registries." They can call the patient, or send this letter, that basically just says "hey it's time to come in, it is important to manage your diabetes" and then we hope the patient comes in. There is no standardized process. We have little pins for improvement if the team (we are separated into four teams) shows improvement in any of the things we measure.

So the registries get passed out to great fanfare and grumbling maybe three times a year, and then there is a flurry of letters, and then some people come in.

I asked the pediatric diabetes clinic in town what they do. They do not do any of this kind of followup. They have an expectation that each of their kids (most but not all with T1DM) comes in every three months.

Just writing this is giving me some ideas... in my spare time, I'd like to re-write the letter, and include the recommendations (like I said above, a1c q3mos if not controlled, q6mos if well-controlled. etc. and also make it easier to read, many of our patients have low literacy.) Mayb ethe easy-read "Please come in, we would love to see you!" at the top and rec's at the bottom.

It really is a clinic-wide process, a team effort, and there is so much other work to do.

Since I got certified as a diabetes educator I am seeing some real improvement in many of our patients, and some improvement in the average a1c's etc.

What has been your experience? Do you feel like you are effective? Make a difference? How are you measuring improvement?