Transformed Team Tracks Kidney Transplant Patients Follow-up Care

Members of the Stockdale Medical Offices nephrology department always met or exceeded regional goals in their discipline. So it was a rude awakening when patient care data showed they were merely average—and that wasn’t good enough. By analyzing the metrics and scouring patient records, the team was able to come up with a plan to provide kidney transplant patients with the right care at the right time. Services include flu shots, renal ultrasounds and lab work.

Here's What Worked

• 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?