38 A proactive outreach approach to prevent primary care patients from falling through the cracks

<h3>Description</h3> Primary care providers (PCPs) focus on patients presenting for care, but access limitations may create care gaps for those impacted by social determinants of health. Proactive Care Coordination Assistants (PCCAs) at Edmonton Southside Primary Care Network proactively outreach to patients, ensuring equitable access for 212 participating physicians. As a result of outreach to patients due for care or preventative screening, colorectal, breast, and cervical cancer screening rates increased from 59% to 61%, 51% to 57%, and 53% to 60%, respectively (figure 1). Diabetes screening rates increased from 74% to 88% (figure 2). Over 90% of patients were seen within the recommended timeframe (figure 3). Panel accuracy, measured by the alignment of registered patients with billing data estimates, also improved after the adoption of this model. With high physician participation in this equitable approach high results are promising for spread and scale.