Improving Chronic Illness Care
Improving Chronic Illness Care

Six: Planned Visits

Change Care for Your First Patient
The next few sections will show how you can start testing practical changes with actual patients. You will be given some guidelines for how to prepare and run planned visits, and how to deliver evidence-based clinical management and self-management support during the visit.

Think about how to make this process real in your practice. How can other staff in your practice be involved? How can you engage the patient as a participant in their own care? Then begin testing - one patient at a time - knowing that you soon will have designed planned care that can be implemented with all patients. You will also learn how to deliver what's known as opportunistic care - planned care in unplanned or acute care visits.

The Planned Visit
Many healthcare providers believe themselves to already be doing “planned” visits. They note that their patients with chronic conditions come back at defined intervals. Yet upon closer inspection, these visits may look a lot like acute care: the provider might lack necessary information about the patient’s care needs; provider and patient might have different expectations for the visit; and staff may not be fully utilized to help with the organization of the visit and delivery of care. These “check-back” visits, while scheduled in advance, are often not efficient nor productive for the provider and patient. Try the following suggestions for organizing the planned visit:

Assign Team Roles and Responsibilities
Use the “roles grid [DOC]” to identify the logistical and clinical tasks necessary for the preparation and execution of the visit. For example, the following questions might need to be addressed: who is going to call the patient to schedule the visit? Who will room the patient? If the patient has diabetes, who will remove her/his shoes and socks? Who will examine the feet? Who will prepare the patient encounter form for use during the visit? All tasks need to be delegated to specific team members so that nothing is left to chance.

Call a Patient In For a Visit
Develop a script for the call, and decide which team member will make the call. Set the tone and expectations for the issues addressed in the visit. Here is a sample script you can adapt to your setting:

"Hello Ms. Smith. This is Karen calling from Dr. Brown’s office. He is interested in making sure all of his patients with chronic conditions are receiving the best possible care. He has asked me to have you come in for visit to discuss your (insert condition here). If you have other health concerns, we may have to address those at a future visit. By focusing on just your (condition here) both you and he can better manage your health.

Can we set up a time that is convenient for you? When you come please bring all your current medications (and anything else pertinent to the condition). Thank you. We will call you a day before the visit to make sure you are still able to come."

If you choose to mail an invitation to patients, be sure to track respondents. Typically, less than 50% of patients respond to a letter. You will need to plan an alternative method of contacting non-responders.
 
Deliver Clinical Care and Self-Management Support
In preparation for the visit, print an encounter form from your registry or pull the chart in advance so that you can review the patient’s care to date. Below is a sample encounter form. Document what clinical care needs to be done during the visit.
The Acute Care Visit and Planned Care
Regardless of how much you plan, patients still arrive unexpectedly with acute exacerbations. Assuming that your patient is stable, use this opportunity to provide all or some of their routine chronic care. You can then fold them into the planned care visit schedule. To take advantage of this opportunity, try the following:

Get As Much Done As You Can
  • Consider developing standing orders for these kinds of visits
  • Make sure the team knows their roles and responsibilities around the standing orders
  • Find or develop a tool to keep track of what you’ve done and still need to do
  • Introduce the concept of self-management to the patient and discuss how you would like them to start having planned visits with your team, and why
  • Schedule their first planned care visit!
Determine How To Meet Regularly
Until new roles are well integrated into the normal work flow, many practices have team huddles for 5-10 minutes in the morning to review the schedule and identify chronic care patients coming in that day for an acute care visit. Decide how best to meet as a team to manage these patients. Determine the best intervals and timing for these meetings, and stick to them. The brief get-togethers help the team stay focused on practice redesign and create a spirit of “one for all”.