Identifying diabetes patients with care gaps

Over 29 million Americans suffer from diabetes, and painful complications can impact systems throughout the body – from kidney function to eyesight.  Arcadia’s chief medical officer Rich Parker, MD has written about the need for a disease management program to support patients managing this condition, noting that, “both forms of diabetes are eminently manageable with good medical care and patient education and self-care.”

Organizations that implement a disease management program for diabetes need to be able to:

  • Accurately identify patients with diabetes – even if their clinical information is spread out over several EHRs
  • Stratify those patients by risk, to deliver appropriate care
  • Identify care gaps that can impact patient health
  • Help physicians and care teams address those care gaps during appointments

Our Arcadia Analytics Quick Guide “Identifying Diabetes Patients with Care Gaps” explains how to use Arcadia Analytics to identify patients with diabetes who have open care gaps and an upcoming appointment – and share that information with the appropriate member of a care team.    You can download it using the short form below.

Want more information? 

We’re always happy to answer questions about using our product in your practice.  You can reach us at

Jennifer Polello, MPHA, MCHES, PCMH CCE

Jennifer is the Director of Product Training at Arcadia Healthcare Solutions, with over 20 years of experience across the healthcare continuum in the areas of public health, chronic disease management, quality improvement, health policy, clinical informatics and project management.  Her extensive knowledge and leadership has enabled Arcadia client success on complex enterprise clinical transformation and care coordination projects.   She is an expert facilitator, leading teams of clinicians, nurses and physicians through the transformation and improvement process of patient care in the ambulatory setting through multiple projects throughout her career.

Jennifer has worked on regional health information exchange (HIE) projects and assisted in the design of a clinical decision support tool for patients with type 2 diabetes.  She has also created and implemented online learning modules for clinical transformation and adoption of electronic medical record systems.  Jennifer has a Master’s degree in Health Policy and Administration from Washington State University and is a PCMH Certified Content Expert.  She brings that knowledge and experience across multiple clinical settings to enhance the training and implementation of Arcadia’s core products.     Under Jennifer’s leadership, Arcadia Analytics clients have been able to use training as a way to move closer to their strategic goals.

November 14, 2016

IT-Enabled Disease Management: Diabetes

Diabetes is one of the six major conditions that should be managed as part of any population health program.  Arcadia chief medical officer Rich Parker, MD explains why organizations taking on value-based contracts need a disease management program for diabetes – and how analytics can help.

Read the article