Mike’s Metrics: Meet Robin—Engaging Prioritized Patient Populations for Critical Outcomes.

by | Jun 29, 2023

In the ever-evolving landscape of healthcare, targeted outreach and patient engagement have become pivotal for improving outcomes and ensuring optimal care. By proactively identifying high-value patients and executing strategic interventions, healthcare providers can effectively manage chronic conditions, navigate care transitions, and implement care plans. In this latest  post part of Mike’s Metrics, we delve into the power of targeted outreach. 

Meet Robin, a 61-year-old outpatient with multiple chronic health conditions.

Robin and her health stats

Identifying High-Value Patients:

Within the realm of healthcare, identifying patients who require prioritized attention is a crucial first step. Tendo Insights, a comprehensive analytics platform, played a pivotal role in identifying Robin as one such high-value patient. Robin’s conditions, including diabetes mellitus, chronic kidney disease, and congestive heart failure, presented a significant health risk. Moreover, missed Annual Wellness Visits (AWVs) could potentially lead to increased utilization and hospitalization.


Reaching Patients Through the Right Channels:

Engaging patients like Robin through their preferred communication channel is vital to ensure their active participation in their own healthcare journey. Tendo helped Robin’s provider leverage targeted notifications to educate her on the importance of AWVs. These notifications were delivered through her preferred communication channel, prompting her to make an appointment. To minimize the likelihood of no-shows, Robin received timely reminders, reinforcing the significance of attending her scheduled appointment. 

Additionally, a few days before the AWV, Robin was provided with a Health Risk Assessment to complete ahead of the visit.  Answering these questions before her visit enhanced the efficiency and productivity of her appointment for both her and her provider.  This also allowed the health system to complete more AWVs with the same number of providers.

Images of the patient care journey app

Engaging Patients with the Right Tools:

Patient engagement is a critical factor in managing chronic health conditions effectively. Robin’s engagement was fostered through personalized reminders from Tendo. These reminders encouraged her to complete relevant surveys in preparation for her appointment and discuss her chronic conditions with her healthcare provider. By providing Robin with the tools to actively participate in her care, Tendo empowered her to take charge of her health and well-being.

Providing the Right Care to Support Patients:

During Robin’s AWV, Tendo facilitated the identification of multiple chronic conditions that required further care and attention. This comprehensive assessment led to the creation of a Chronic Care Management (CCM) visit for Robin. The CCM visit enabled her to receive improved care and resulted in referrals to new specialists, ensuring that her chronic conditions were comprehensively addressed. By implementing appropriate care plans and follow-up referrals, Tendo ensured that Robin’s health conditions were effectively managed.

Ensuring Continual Progress Through Follow-Up:

To support Robin’s ongoing progress and maintain effective communication, Tendo offered the Patient Care Journey app. This intuitive application allowed Robin to easily access her personalized care plan and share it with her caregivers. With features such as text, chat, email, and virtual visits, Robin could conveniently communicate with her care team, ensuring continuity and timely follow-ups. The app also provided reminders, enabling Robin to stay on track with her care plan and fostering a strong connection between her and her care team.  She and her caregiver children could also easily see all of her referrals and upcoming appointments at a glance to ensure that they were all planning their lives easily.

In Conclusion:

Robin’s journey exemplifies the power of targeted outreach and proactive healthcare management. By identifying her as a high-risk patient and implementing timely interventions, Robin’s chronic conditions were effectively addressed, leading to improved health outcomes. With ongoing support, education, and a strengthened connection with her care team, Robin experienced a renewed sense of control over her health. She even had the pleasure of enjoying a weekend with her grandchildren in New York City, confident that her health conditions were under control.

To learn more about how Tendo is solving the challenge of reaching and helping Robin visit Tendo Outreach

Mike Burton

Mike Burton

VP, Value Engineering

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