This Patient Registry is intended to provide physicians the opportunity to start managing their patient population.

The guidelines described for each condition are of descriptive nature and for illustrative purposes only.
It is the physician's choice to track one or more conditions.
The Patient Centered Care Consultant will gather the guidelines you would like to use for the chosen condition and deliver the tool with such information.
Once this tool is implemented and conditions tracked, the Patient Centered Care Consultant will help identify areas of improvement and/or workflow analysis and redesign.

Please contact your Patient-Centered Care Consultant

Take Action

Identify values outside parameters, discuss if campaign to improve outcomes is needed. Consider holding specific clinics

Approach

Holistic; while condition focused.

Value

Help organize physicians; to sort patients' conditions to identify gaps. These gaps may or may not mimic Anthem reports.

Critical Condition Element

Critical Condition Element

Critical Condition Element

Critical Condition Element

Diabetes

Abnormal when:

CHF

Abnormal when:

CAD

Abnormal when:

Asthma

Abnormal when: COPD

Abnormal when:

BP

>140/90

BP

>140/90 >150/90,over 60

BP

>140/90 >150/90,over 60

Fasting lipid profile date

Fasting lipid profile - LDL
Statin
BMI
Medication use counsel

>1 year
.>1 yr
No
>24.9
No

Fasting lipid profile date

Fasting lipid profile - LDL
Statin
BMI
Medication use counsel

>1 year
.>1 yr
No
>24.9
No

Fasting lipid profile date

Fasting lipid profile - LDL
Statin
BMI
Medication use counsel

>1 year
.>1 yr
No
>24.9
No

Peak Flow Measurement

Baseline Spirometry
Asthma Action Plan
Home/environmental counsel
Medication use counsel

No
No
No
No
No

Peak Flow Measurement

Baseline Spirometry
Peak Flow Measurement
Oxygen Dependent
Medication use counsel

No
No
No
Yes
No

EF documented

No

Aspirin

No

Compliance with Rx
oxygen
Exercise Rx

No
No

ER Hospitalization

Yes

ER Hospitalization

Yes

ACE/ARB, if BP and/or urine

microalb abnl

No

EF<40%, ACEI/ARB

No

Aspirin&/or Clopidigrel(if
DM+CVDrisk)
AIC
AIC date

No
>7
> 6 months

EF<40%, Bblocker
Aspirin, (if CVD risk)

No
No

Daily Weight/ Change

>=4lbs over "target wt"
Dynea,orthopnea
Edema

Increased
Increased
Increased

ER Hospitalization

Yes

Retinal Exam Date

> 1 year

Foot Lesion/Neuropathy Exam

Date
Urine Microalbumin date
Urine Microalbumin Value
Serum Creatinine Date

> 1 year
>1 year
> 30mg/24hr
>1 year

Serum Creatinine; nephrologist

referral
< 2 ( eGFR<60)
ER Hospitalization
Yes

ER Hospitalization

Critical Condition Element

Yes

Patient name

Gender

DOB

Clinician

BP

Fasting lipid
profile date

Statin

BMI

Medication
Use Counsel ACE/ARB

Aspirin
and /or
Clopigrel(if
DM + CVD
Risk)

AIC

AIC date

Urine
Foot Lesion/
Urine
Serum
Retinal Exam Neuropathy Exam Microalbum Microalbumin Creatinine
in Value
Date
Date
date
Date

Serum
Creatinine
Nephrologist
referral <2
(eGFR<60)

ER/
Hospitalization

Dietary
Counsel

Tobacco Use

Exercise
Counsel

DM Self Mgmt
education:
Flu Vaccine
monitor BG
Date Yearly

Pneumo
Vaccine
Hep B
(consider
Vaccine
repeat if >65) series

Patient name Gender

DOB

Home/
Medication
Peak Flow
Baseline
Asthma
Environmental use
ER/
Clinician Measurement Spirometry Action Plan counsel
counsel
Hospitalization Tobacco use Exercise

Pneumovax,once,
Flu, yearly (consider repeat if>65)

Patient
name

Gender DOB

Baseline
Clinician Spirometry

Date

Peak Flow
Measurement

Oxygen
saturation
%

Oxygen
Dependent

Medication
use counsel

Compliance
with Rx
Exercise
oxygen
counsel

ER /
Hospitaliza
tion
Tobacco Use

Flu Vaccine
Date

Patient Name

Gender DOB

Clinician

Fasting
Blood
Lipid
Pressure Profile

Statin

BMI

Medication
Use Counsel Aspirin

ER/
Hospitalization

Diet
Counsel

Tobacco
Use

Exercise
Counsel

Flu
Vaccine
Yearly

Pneumovax
(Consider
Total
repeat if >65) Cholesterol

Hep B
Immunization
Series

Patient Name

Gender DOB

Clinician

Blood Pressure

Fasting
Lipid
Profile

Statin

BMI

Medication EF
Use
Documente EF <40%
Counsel
d
ACE/ARB

EF<40%
Bblocker

Total
Cholesterol Aspirin

Daily
weight/change>
4lbs over "target Dyspnea/
weight"
Orthopnea

Edema

ER/
Hospitalization

Dietary Counsel Tobacco Use

Alcohol use > 2

per day

Exercise
Counsel

Flu
Vaccine
Yearly

Pneumovax
(consider
Hep B
repeat if
Immunization
>65)
Series

PHQ9
Score (Must
Patient name

Gender DOB

Clinician

Contact Date

PHQ2
Score

be completed
if PHQ2 is
positive)

GAD 7
Score

BH
BH Referral Provider

BH Follow
up Date

BH
Rescreen
Date

AUDIT Substance
Use Screen
Score

Substance
Use
Substance Use
Referral
Follow Up Date

Substance Use
Rescreen Date

Medication Use
Counsel

Co-Morbid
Condition

On Medical
Condition
Registry

Patient Name

Gender

DOB

Target
Current Presence Lab Data Serum
Blood
Blood
of risk
Serum
Creatinine
Clinician Pressure Pressure factors
K+
(eGRF)

Cholesterol
and LDL

HbA1c

Urine/albumin
creatinine

CBC

BMI

ER/
Medication Use Hospitali Diet
Counsel
zation
Counsel

Flu
Tobacco Exercise Vaccine
Use
Counsel Yearly

Pneumova
x
(Consider Hep B
repeat if
Immunization
>65)
Series

References
Asthma Health Team Works, (n.d.) Asthma Care Flowsheet. Retrieved from http://healthteamworksmedia.precis5.com/140f6969d5213fd0ece03148e62e461e
Health Team Works, (n.d.) Asthma Care Flowsheet. Retrieved from http://healthteamworksmedia.precis5.com/c6335734dbc0b1ded766421cfc611750
COPD Gold COPD, (n.d.) Retrieved from http://www.goldcopd.org/uploads/users/files/GOLD_AtAGlance_2013_Feb20.pdf

CAD - https://collaborate.wellpoint.com/sites/PCPC_Team/Transformation%20Strategy/PC2%20Change%20Packages/CAD%2
%20Package/CAD%20Provider%20Resources/Cardiovascular%20Care%20Flow%20sheet.pdf
Reference:http://www.ndei.org/ADA-2014-guidelines-diabetes-diagnosis-A1C-testing.aspx
http://circ.ahajournals.org/content/121/24/2694.full.pdf

Behavioral Health http://www.phqscreeners.com/overview.aspx?Screener=03_GAD-7

Website instructional manual on PHQ and GAD screeners for Depression and Anxiety - link also on our Provider Toolkit
http://www.integration.samhsa.gov/clinical-practice/screening-tools
Provides a variety of screening tools available - depression, anxiety, drug/alcohol use, bipolar, suicide risk, and trauma
For depression

Patient Health Questionnaire or PHQ. A score of 3 or higher on the PHQ-2, suggests the need for additional evaluatio
would then administer questions 3-9 of the PHQ-9. The PHQ-9 rates the level of depressive symptoms as Mild, Moder
Moderately Severe or Severe.

5-9 is Minimal symptoms - offer support, educate to call if worse, return in one month
10-14 is Minor depression, Dysthymia, Major Depression, mild - support, watchful wating; anti-depressant and/or psyc
15-19 is Major depression, moderately severe - antidepressant and/or psychotherapy
20 or greater is Major depression, severe - antidepressant and psychotherapy (especially if not improved on monother
The Edinburgh Maternal Depression tool is used to assess pre and postnatal women
For substance abuse, measures are often separated out for alcohol vs drug use.
The AUDIT and the CAGE are brief assessments of alcohol use and help identify use at hazardous levels, as well as
dependence.

Scoring: Sum total points. A score of 8 or higher indicates a drinking problem; Reference: Saunders, J.B. et al (1993). Developm
Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with harmful Alcoh
Consumption-II. Addiction, 88, 791-804.

Risky Drinking: Women: More than 7 drinks per week OR more than 3 drinks per occasion. Men: More than 14 drinks per week
than 4 drinks per occasion. Reference: U.S. Preventive Services Task Force, Recommendations for Alcohol Screening, Adults
The CRAAFT assess use of alcohol and other drugs, as well as risky behaviors in adolescents

http://www.nchealthliteracy.org/hfselfmanage.html
http://www.cardiology.org/recentpapers/susiechfc.pdf
http://circ.ahajournals.org/content/119/14/1977.full.pdf