Complications from this disease include damage to the eyes, kidneys, nerves, heart and blood vessels. Therefore, an approach that helps physicians track and manage their patients with diabetes, can have an impact on a wide range of health concerns among the Medicare population. Delmarva has coordinated mailings to remind Medicare patients to get diabetes care, immunizations, and mammograms. The processes can be used for other health conditions, such as PSA testing and osteoporosis screening, which are also covered by Medicare. Since Delmarva's work is primarily with the Medicare population, data retrieval has been focused on those beneficiaries, but searches to identify Medicare patients who are also medicaid recipients have also been performed, in order to focus on the very vulnerable dually eligible population of low-income older Marylanders.
Practices can expand their notification systems to patients with any insurance coverage.
With any type of intervention, attempts should be made to measure the impact. Performance improvement systems can also be designed around established electronic systems currently in use in physicians' offices. Practices that bill for laboratory work done onsite can use their billing systems to quickly determine if patients receiving the reminders followed up with HbA1c and lipid testing in the six months following the mailing. The number of patients receiving recommended immunizations can also be determined from billing systems, once the targeted population is identified. Delmarva has also assisted practices to create enhanced referral systems with laboratories or specialty physicians, i.e., ophthalmologists sending eye exam reports and radiology centers sending mammogram reports, so that the primary care practitioner can have the loop closed in the referral process.