Helping patients through proactive screening efforts

Our Health Information Coordinators (HICs) and Patient Care Coordinators (PCCs) work together to support clinics through proactive screening and outreach initiatives.

These efforts form part of our Screening and Prevention Program and Chronic Disease Management Program, helping you keep patients healthy and engaged in their care.

The steps of this process include:

Step one: Identifying patients

HICs use EMR data along with Alberta Screening and Prevention (ASaP) guidelines (provincial preventive screening recommendations) to identify patients that are eligible for proactive screening. Members and their PMH teams can also choose projects that align with a clinic’s priorities.

Step two: Coordinating care

Once a quality improvement project is selected, the PCC works directly with patients to schedule appointments, update charts, and gather information when needed. This coordination helps reduce the team’s administrative load and ensures patients receive timely follow-up.

Step three: Tracking progress

PMH teams use Monday.com to track and manage project progress. Updates are also shared during PMH meetings, and members with PMH teams can log in anytime to review project status. This ensures transparency and keeps everyone aligned.

Why it matters:

These proactive screening projects, grounded in demographic and EMR data, help identify care opportunities earlier, close preventive care gaps, and support healthier patient populations.

You can learn more about our outreach and screening support anytime on our website.