Planned Care at Every Visit

1. Planned Care at Every Visit Connie Sixta, RN, PhD, MBA Patricia L. Bricker, MBA

2. What is “Planned Care at Every Visit”? • Definition of “Every Visit” includes acute, sick, urgent, walk-in, and follow-up visits • Awareness of patient chronic illness and prevention needs at every visit • Completion of unmet clinical guidelines at any and all visits as appropriate • Access principle: max-pack evidence-based tasks at each visit to enhance access

3. Why DoPlanned Care at Every Visit? • Complete necessary chronic illness/condition and prevention guidelines • Stay ahead of the risk • Promote more frequent measurement of high-risk or problem areas (BP) • Catch patients who otherwise refuse to come in for follow-up care • Reduce the need for additional visits and rework by max-packing care

4. Critical Changes That Support Planned Care at Every Visit • Alert system for the population • Automatic reminder of unmet clinical guidelines (some EMRs have default mechanism) • Expectation to complete as many clinical guidelines as possible • Assess current risk status and initiate new or additional interventions to manage outcomes • Arrange follow-up visits for high-risk patients

5. Population Alert Systems • Alert appears on the schedule or when the EMR is opened to a patient in the population • Supports pre-visit planning and preparation

7. Automatic Reminder of Unmet Clinical Guidelines • Awareness of clinical guidelines that can be completed during that visit • Allows initiation of standing orders by staff

9. Complete as Many Guidelines as Possible Each Visit • Culture change – get today’s work done today • Approach balances work flow over time • Requires less scurrying and extra visits to complete guidelines • Additional opportunities to focus on problem areas

10. Assess Current Risk Status and Initiate Interventions • Earlier identification of patients whose risk or disease severity has increased • Earlier interventions to decrease risk • Change or add medications (JUST DO IT!) • Referral to other team members for appropriate interventions. • Closer follow-up visits • Prevent complications, ER visits, hospitalizations, sentinel events

11. Key Process Key Process Key Key Process Process Key Beginning Beginning Beginning Beginning Beginning Planned Care at Every Visit Patient schedules appointment; Population alert activated MA reviews guidelines and reminders to identify needs MA activates pre-visit standing orders when possible Patient arrives MA & Provider discuss needs, risk status, and plan of care (huddle) MA rooms patient, implements standing orders, discusses patient action plan, completes risk assessment form Provider reviews patient status, prescribes meds, reinforces action plan, plans follow-up care Patient leaves with scripts, status report, patient action plan, and follow-up plan MA reviews instructions, closes the loop, sets up follow-up call

12. Questions