Screening and prevention: A team-based approach

As part of our Screening and Prevention Program (SaPP), our Health Information Coordinators (HICs) and Patient Care Coordinators (PCCs) work collaboratively to identify at-risk patient populations and coordinate targeted outreach.

A three-step process to proactive care:

1. Identifying screening opportunities: Our HICs utilize EMR data along with Alberta Screening and Prevention (ASaP) guidelines to identify proactive screening goals that would benefit the largest number of patients in a panel. Physicians can also select quality improvement (QI) projects that align with their clinical interests.
2. Coordinated patient care: Once a project is chosen, our PCC takes the lead in engaging patients: Scheduling appointments, updating charts, cross-referencing Netcare, and managing any necessary information transfers. This ensures timely and efficient screening interventions.
3. Ongoing project tracking and communication: PMH teams use Monday.com to monitor project progress and share updates during annual meetings. This platform allows team members to track milestones and ensure alignment on project goals.

Why it matters:

• Proactive screening initiatives, guided by demographic insights and evidence-based practices, play a crucial role in maintaining the health of patient populations.
• By identifying potential health risks before they develop into more serious conditions, patients can receive timely interventions and reduce the burden of chronic disease.

You can learn more about our programs and services on cwcpcndocs.com.