Data source for following is EMR:

DATA MATRIX

The matrix is a combined data search on 4 different indicators pertaining to diabetes. The concept is that it flags the most “at risk” patients and allows to act proactively on their care.

September 2019:? ? ? ? ? ? ? ?8 patients identified as at risk and each patients provider was notified as such.

January 2020:? ? ? ? ? 11 patients identified as at risk and each patients provider was notified as such. 2 patients were carry over?

->47 patients being tracked that are on TWO of the lists over time and? notify providers when on lists for 6 months consecutively

Queries were developed in the EMR with clinical staff to set the limits