Health Maintenance (Care Gap) Reminders

The "Health Maintenance" activity is a tool within Connect Care for monitoring and addressing tasks or orders needed to keep a patient’s preventive or chronic disease management up to date. Connect Care applies a set of logic-based rules, based on population-level clinical practice guidelines and validated within the AHS context, to identify individuals in which health tasks may be due. Providers are presented with "health maintenance reminders" to encourage consideration of care gaps and appropriate actions.

Care Gaps

When a Care Gap is identified, providers have several options to address it.

First, the clinician may disagree and provide information that resolves the gap. For example, an indicated screening test (e.g., pulmonary function) may have been performed outside Connect Care's reach and is, in fact, complete. Relevant details can be entered to Connect Care. This improves the patient's Connect Care health record while also preventing repeat gap notifications.

Second, the clinician may feel that the patient's risks merit a different frequency or type of health intervention. Risk factors can be adjusted. The intervention due or follow-up date can be postponed. If a particular care gap or intervention is no longer relevant for a patient (e.g., compassionate care), that too can be indicated and the gap will not be re-flagged.

Finally, the clinician can heed the gap prompts and take indicated actions.

Care Gaps may be highlighted in different Connect Care areas:

  • Patient Storyboard

    • Note: A Care Gaps flag appears on Storyboard when the client is due for screening or preventive care follow up.

  • Health Maintenance activity

    • Selectable as an activity tab for any open chart, or found by using global search for "maint" (then "Jump to" health maintenance)

  • "Plan of Care" section in the "Chart Review" activity

  • Patient Portal (MyAHS Connect)

More information about Health Maintenance/Care Gaps:

Health Maintenance Plans

Health Maintenance Plans focus on anticipatory actions that clinicians can take to help patients prevent serious illness in the future. A few plans are already active in Connect Care, with others being developed and validated for Albertans over time:

  • Cervical (Pap Test) for cervical cancer prevention

  • Colonoscopy for colon cancer prevention

  • Diabetes Health Maintenance Suite (including Hemoglobin A1C, lipid, foot screening, nephropathy screening and retinopathy screening for prevention of complications associated with diabetes mellitus)

  • Prenatal Sexually Transmitted Infection (STI) screening