Care Coordination
Establish HIPAA-compliant reporting systems with the vendor to track patient uptake, retention, and satisfaction.
Process
In coordination with FIM vendors, identify and address challenges in program uptake, retention, and satisfaction.
Technology
Develop EHR flags when indicators on patient uptake, retention, and satisfaction are low.
Establish systems for clinical care teams to securely message patients to resolve challenges.
Personnel
Instruct clinical care team to monitor flags in EHR and initiate and respond to patient messages to address challenges.
Schedule follow-up appointments three to six months after referral to monitor progress.
Monitoring
Reassess food security status and clinical indicators at follow-up appointments to determine continued program eligibility.
Process
Establish automated appointment reminders for follow-up visits every three to six months to track changes in clinical and social health metrics.
Deliver follow-up assessment forms, including food insecurity reassessment, through an online patient portal before the visit or at check-in, or through paper forms at appointment check-in or in rooming.
Recognize and respond to EHR BPAs that necessitate a new or re-referral to another clinical team, in-house program, or external vendor.
Technology
Build reassessment forms to track targeted clinical and social outcomes related to FIM program participation.
Integrate BPAs within follow-up visit forms to indicate continued FIM program eligibility.
Personnel
At patient check-in, clinical support staff confirm that food insecurity re-screening has been completed. If not complete, collect in clinic during rooming and input result into the EHR.
Train providers to identify changes in patient health outcomes at follow-up visits, including the need to adjust medications.