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SHMG Planned Care Visits for Diabetes. Sherrie Damstra, LPN, Clinical Lead Spectrum Health Medical Group sherrie.damstra@spectrumhealth.org December 6, 2013. 4 Steps. Pre visit planning / ”Chart prep” Planned care visit Follow up care Working the “gaps”.
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SHMG Planned Care Visits for Diabetes Sherrie Damstra, LPN, Clinical Lead Spectrum Health Medical Group sherrie.damstra@spectrumhealth.org December 6, 2013
4 Steps • Pre visit planning / ”Chart prep” • Planned care visit • Follow up care • Working the “gaps”
Pre-Visit - “Chart Prep” - Diabetes • The day prior to the visit the clinical staff reviews the chart to determine if the condition specific labs were completed and ensures the results are available in the medical record. -A1C -Lipid Panel -MicroAlbumin / CreatinineUrine Ratio -BMP • Update Health Maintenance and review flags to capture any other care opportunities. • Gather any other information pertinent to visit type such as a Retinal Exam. • Discuss special patient needs at huddle if appropriate.
Planned Care Visit - Diabetes • Clinical staff obtains appropriate vital signs, and performs any appropriate point of care testing such as A1C, Micro/Alb /Creat, visual foot exam and monofilament. • The clinical staff reconciles patient’s medication list, including adding new meds from other providers and refilling meds per medication refill protocol, adding OTC meds and updating medication allergies. • If the patient has an elevated blood pressure, clinical staff flags the door with the “blue dot”. • Clinical staff reviews Health Maintenance flags and update/order as appropriate following the Standing Orders guidelines. • The physician reviews the patient record at the time of the visit to determine future care needs and lab monitoring/frequency needs. • The patient is scheduled for the next follow up appointment based on clinical findings.
Follow up Care • A reminder call is placed 2 days prior to the next visit. • So……….what if the patient cancels or no shows?
Working the Gaps • Gaps reports are produced monthly by disease state and provider. • Reports include all patients, regardless of payer. • Reports are distributed to staff to “work”. • Calls are placed or reminder letters sent to patients for ANY gap in care including preventive health. • Lab orders are entered as needed.
