Stepped Approach to Preventive Services Outreach in Primary Care


To improve colorectal cancer screening, breast cancer screening, cervical cancer screening, pneumococcal vaccination, and influenza vaccination among patients in UNC Physician Network clinics.




Many patients have care gaps in colorectal cancer screening, mammography, cervical cancer screening, and vaccination. Preventive care in UNC Physician Network practices varies based on the limited population management infrastructure of each practice. Some clinics employ visit-based prompts for a few preventive care tasks and some use staff to create prompts for the providers. No clinics use prompts for all five of these prevention services.

We need to move beyond visit-based care and introduce interventions based on a philosophy of population management. No clinic has a defined process for outreach for all five of these prevention services. Healthier patients who rarely visit the doctor do not receive reminders for important prevention services. Patients who come in frequently because of complicated medical problems often do not have preventive care needs met.

Patients who do not receive recommended preventive services as a result of visit-based prompting or limited outreach receive no other assistance from the clinics to seek preventive care.

Team Leaders

Shana Ratner, MD


July 2014 - June 2015