作为初级保健提供者(PCP)，您了解缩小质量和护理差距的挑战. Landmark helps PCPs close quality care gaps in multiple ways. Imagine the following scenario:

Joe is a patient with multiple chronic conditions. 他每年看一次，也许两次PCP，并且在质量上存在需要解决的缺口. Health plans place financial incentives on closing these care gaps, but more importantly, they are a key aspect in preventative, value-based medicine.

Patients like Joe may struggle to make it to their PCP on a consistent basis, which means the time Joe spends with his doctor is important. 初级保健提供者正在把越来越多的预约挤进一天，导致他们花在慢性病患者身上的时间不够, co-morbid patients like Joe. 无论乔是因何种疾病进入办公室，缩小医疗质量差距都是次要的. Care gap closures frequently result in referrals to the laboratory, ophthalmologist, gastroenterologist, or other specialists. While these referrals can turn into care gap closures, many times they do not.

Roadblocks to Gap Closures

Coordination of necessary follow-up activities, combined with patient compliance (including attending multiple appointments), is a major challenge. 对于一个治疗满载病人的初级保健提供者来说尤其如此. For average patients, follow-up is completed during the next timely appointment; but when Joe only visits every 6–9 months, it can be cumbersome to ensure that a care gap closure is completed.

Landmark Helps Close the Gaps

乔可以很容易地通过他的高质量医疗差距的弥补——但他不必这样做. 想象一下，有一个团队来帮助补充忙碌的初级保健提供者的工作. A team that conducts point-of-care testing with Joe to close his HbA1c control care gap; a team that helps Joe schedule a colonoscopy and encourage him to make it to his appointment; a team that does an in-home retinopathy screening so that Joe doesn’t need to drive to see an ophthalmologist. Landmark Health looks at health care through a different lens; Landmark enhances Joe’s health care experience and assist PCPs in extending their care beyond the office and into Joe’s home.

Landmark Health是一家专注于为大多数慢性病患者提供家庭医疗护理服务的医疗集团. Landmark augments the services provided by PCPs, such as assisting in the quality care gap closure process. 在患者家中，Landmark服务提供者和其他跨学科团队(IDT)成员有机会花费额外的时间来弥补护理差距，例如全面的糖尿病护理, colorectal cancer screening, depression screening and follow-up, 以及其他措施，忙碌的PCP可能没有时间在传统的办公室访问期间完成.

让我们看看Landmark在传统低依从性人群中提高高质量护理差距的三种方式.

1. Comprehensive Diabetic Care (CDC)
CDC有三个与CMS星级评定系统- hba1c控制相一致的主要措施, nephropathy screening, and retinopathy screening.

• HbA1c Control and Nephropathy
  具有里程碑意义的医疗机构有HbA1c和尿蛋白定点设备，可以进行现场筛查. A key advantage to on-the-spot, 即时检测的优点是无需确保患者安排并前往实验室检测设施. Results are given to the PCP and are sent to the health plan using CPT codes, ensuring the patient does not appear on the next health plan care gap report. The PCP is credited with the closure.
• Retinal Screening
  Landmark team members are trained to use a retinal screening camera. 该相机可以拍摄患者视网膜的照片，然后安全地发送给眼科医生，以诊断眼部相关疾病, including retinopathy. 像乔这样的复杂病人被转介给眼科医生，可能无法按时赴约. 错过的预约可能永远不会重新安排，糖尿病视网膜病变的护理差距可能永远不会缩小. 将视网膜病变筛查带到患者家中可以确保弥合护理差距，并减少患者的麻烦. 这些报告通常在图像捕获后24-48小时内交付，然后发送给PCP进行审查. Finally, 它们使用必要的CPT和ICD-10编码自动发送到现金足球网哪个好计划，以确保适当的护理差距和PCP信用.

2. Colorectal cancer screening (COL)
结肠护理缺口可以通过多种方法弥补——主要的两种方法是FIT试剂盒或结肠镜检查. When referred for a colonoscopy, Landmark团队共同努力，确保患者安排并参加结肠镜检查预约. 这项工作可以包括通过三方电话帮助病人安排预约, reminding the patient of their upcoming appointment, and ensuring that they have transportation to and from their appointment. If the patient prefers to complete a FIT Kit, Landmark will not only deliver the kit to the patient, but can help complete the necessary lab order form, and can help ensure the completed kit is placed in the mail.

3. Behavioral Health Screening
Another important care gap to close is Depression Screening and Follow-Up (DSF). A PCP may conduct a PHQ-2 or PHQ-9 depression screening, but when a patient requires follow-up care due to a positive screening, this typically results in a referral. Follow-up care for this measure is time-sensitive—requiring care within 30 days. 患者很难在30天内与行为现金足球网哪个好提供者预约并保持预约. Landmark’s team coordinates follow-up care for these patients, 确保他们在规定的时间内得到护理，并根据需要持续得到护理，以控制他们的抑郁症. Follow-up care is completed in the home at the patient’s convenience, to ensure they receive this service when they need it most.

Landmark Health looks at health care differently. Landmark看到了当今初级保健提供者面临的挑战，并帮助将护理从办公室扩展到家庭. Landmark的独特服务包括在家中与患者一起缩小质量护理差距，例如传统的CMS Star措施(例如.g. HbA1c control), non-Star measures (e.g. 抑郁症筛查和随访)，以及其他可以量身定制以满足护理需求的方法. Landmark’s execution of quality care gap closure, in addition to the other services delivered, 允许初级保健提供者专注于更深层次的急性和预防方面的病人护理.