Comprehensive diagnostic testing, interventions, education and rehabilitation.

EPN Diabetes Patients with 2 Visits in the Prior 12 Months

Initiative      Comprehensive Diabetes Care
Metric   Appropriate Office Follow Up
Definition   Patients with Diabetes age >18 seen by their Primary Care Physician at least 2 times in the  past 12 months
Measurement   Percentage of patients meeting the metric definition
Numerator   Number of patients seen twice in the past 12 months
Denominator     Number of patients with a Diabetes diagnosis in their EPICare problem list
Exclusions  

Patients residing in a nursing home
Patients new to EPN within the last 6 months
Patients with a new Diabetes diagnosis within the past 6 months
Patients referred to an Endocrinology Specialist for care

EPIC
Support
  Monthly reports distributed to practices identifying patients overdue for visits     
Network
Goal
    >90%

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