“The proactive care management approach and tools changed how we run the diabetes center. Before we had thousands of patients and many different providers who referred to different specialists as needed, and we did not have a good communication system. Now we are organized into smaller teams with all of the specialty roles working together, our teams meet regularly, dashboards provide immediate access to data to quickly identify patient issues, and providers can readily see their patient populations and determine who needs extra attention.”

Physician, Diabetes Team Leader

“Our care management reports in the electronic health record have increased our clinical team efficiency. Before everything was paper-based. We passed around spreadsheet files and had to manually enter the medical record number on the spreadsheet to access records and contact patients. This was very cumbersome and inefficient and there were many errors. Now, everything is built into the electronic health record, we have patient lists, and we can easily open their charts without ever having to type in a medical record number.”

Manager, Primary Care

“I use these tools and approaches for capacity management, in order to open beds for new patients. We can look at our patients in many different ways: Medical complexity, intellectual disabilities, outpatient visits, service utilization, emergency department visits, and more. Before we only had admission data. This new information helps us figure out why patients are using different services and shows where we can open up resources.”

Nurse Practitioner, Adolescent

“It has been game changing on many levels. We are such a big institution, and there is a lot of information buried in the electronic health record. With these reports and analytics, we are able to understand the needs of each patient and meet them where they are. If we did not have this information, that patient experience would not be where it is now. It helps you be more proactive with care and follow up quickly. Otherwise, you are going through hundreds of charts to see trends and do outreach. You cannot deliver the same level of care without them.”

Nurse Manager, Care Management

“This program does an amazing job and provides a much-needed service for families who often feel the burden of being their child's parent, advocate, nurses, and scheduler all at once!”

Family, complex care management program