Transcript What a Registry Can do for the Practice Team

System Changes and Interventions:
Planned Care
Mike Hindmarsh
Improving Chronic Illness Care,
a national program of the Robert Wood Johnson Foundation
IDCOP National Summit
Chicago
May 13-15, 2002
Delivery System Design
• Define roles and delegate tasks amongst
team members.
• Use planned visits to support evidence-based
care.
• Build effective case management skills into
practice
• Assure continuity by the primary care team.
• Assure regular follow-up.
Roles in Team Care
ROLE
PRIMARY
CARE
PROVIDER
PRIMARY
CARE
NURSING
STAFF
MEDICAL
SPECIALIST
CLINICAL
CARE
MANAGER
RESOURCE
COORDINATOR
CLERICAL
STAFF
Group Visits: A Primer
• Patients brought in by clinically relevant groups
• Patients can receive:
Specialty service as needed/available
One-on-one with medical provider
Medication counseling
Self-management support training
Social support
• Multiple Models for Group Visits
What is a Planned Visit?
• A Planned Visit is an encounter with the patient
initiated by the practice to focus on aspects of
care that typically are not delivered during an
acute care visit.
• The provider’s objective is to deliver evidencebased clinical management and patient selfmanagement support at regularly scheduled
intervals without the “noise” inherent in the
acute care visit.
What does a Planned Visit look like?
• The provider team proactively calls in patients
for a longer visit (20-40 minutes) to
systematically review care priorities.
• Visits occur at regular intervals as determined
by provider and patient.
• Team members have clear roles and tasks.
• Delivery of clinical management and patient
self-management support are the key aspects
of care.
How do you do a Planned Visit?
You Plan It!
Step One: Example Senior Care
Polypharmacy
• Choose a patient sub-population, e.g., all
patients >75 on five or more medications
• Have programming support person or
pharmacy generate list of patients and
medications
• MD reviews list for patients at highest risk
(see handouts)
Step Two: Patient Outreach
• RN/LPN/MA checks to see if patient is on any
registries
• Have PCR call patient and explain the need for
planned visit
• Allow patient to choose day and time for visit
• Ask patient to bring in bag of all medications they
are taking
(including OTCs and herbals)
Step Three: Preparing for the Visit
• RN/LPN/MA prints any relevant patient
summaries from registries and attaches
to front of chart
• MD reviews medications prior to visit,
and consults with pharmacy as needed
Step Four: The Visit
• Review patient’s medication regimen
• Identify and eliminate unnecessary drugs
• Adjust remaining medications as needed
• Problem solve adherence issues with patient
• Create an patient action plan
• Schedule follow-up
Follow-up
• Does not need to be in-person visit (use
phone, email)
• Check adherence to action plan
• Problem solve as needed
• Schedule additional follow-up as needed