• Hosting a short-term special clinic for post-transplant patients, enabling them to get all their follow-up care in one visit
• Creating an Excel spreadsheet of post-transplant patients and their follow-up needs
• Making outreach calls to patients with care gaps

What can your team do to fill patient care gaps? What else could your team do to proactively meet patient needs?

• Making a joint commitment that when there is a KP HealthConnect® notification that a patient is due for a health screening, team members follow up by offering to schedule the patient for the screening or asking the necessary questions to fill in missing information in the patient’s medical record
• Creating a script to help staff members talk to patients about updating their health needs and posting laminated cards on computers to serve as reminders
• Reporting the weekly screening numbers to staff members so they can track their progress and recognize where they missed opp

• Measuring level of staff engagement with patients and successful screenings
• Coaching and peer-to-peer training of staff
• Building physician awareness and education

What can your team do to increase staff and patient engagement? What type of coaching does your team need to be succesful? 

• Printing out registration slips with questions regarding smoking, so smokers can identify themselves up front
• Attaching the registration slips to clipboards, so when patients hand the materials to the genetics counselors, the counselors can provide smoking cessation information

What can your team do to help members know what type of programs are available to them?