Chronic Conditions - Key Activity 10

KEY ACTIVITY #10:

Develop or Refine and Implement a Pre-Visit Planning Process


 

This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction.

Overview

This key activity provides guidance for how the care team can effectively and efficiently embed preventive care measures into the practice’s pre-visit planning (PVP) process. PVP is typically driven by the medical assistant with help from other care team members. It includes steps taken:

  • At the end of the current visit to ensure the patient understands any actions they need to take and to schedule for any follow-up.
  • Prior to a scheduled appointment to “scrub” the chart and identify any pre-visit tasks per the pre-visit checklist.
  • The day of an appointment, during the daily huddle and before the patient sees the primary care provider (PCP).
  • Related resource: Care Team and Workforce Resource 4: Daily Huddles Overview and Process.

The average medical visit at California practices lasts just 15 to 20 minutes, and many patients come to these visits with multiple needs. Pre-visit planning works towards optimizing a team-based approach outside of these short primary care visits so that patients receive comprehensive care in alignment with the latest clinical guidelines and their own preferences.

Pre-visit planning allows for better coordination of care. This can be particularly beneficial for patients with complex health needs, ensuring they receive comprehensive and equitable care. As your practice works to reduce any identified equity gaps, PVP is often a powerful activity for ensuring culturally relevant care as the care team partners with the patient to discuss follow-up actions.

The PVP should incorporate your practice’s process for screening and responding to social needs, including checking whether social needs screening is due. When social needs are identified, the team should be clear on the pathways, both during and after visits, to address and follow up on those needs.

PVP draws upon similar technical enablers as care gap reporting. Likewise, it can be facilitated at the level of the individual patient and at the level of groups of patients coming for a specific team’s care in an appointment schedule block. The format in which planning is done needs to consider the workflow and staffing model.

Relevant HIT capabilities to support this activity include care guidelines, registries, clinical decision support, care dashboards and reports, outreach and engagement, and care management/care coordination (see Appendix E: Guidance on Technological Interventions).

Individual patient-level PVP would optimally be enabled within the EHR, provided the EHR is able to store relevant information, such as assessments, plans, orders and notes outside of a visit note. PVP might also include use of patient-facing applications, such as portals reminders, questionnaires and self-completed screenings/assessments, which ideally would be available to the clinician and care team in the EHR.

Engagement of the expanded care team in PVP requires access by all relevant members of the care team to contribute to and view relevant information. This may require coordination with technology additional to the EHR, such as care coordination and population management applications where relevant information might be stored.

Huddle reports, in which individual patient information can be visualized in summary views across all patients within a session, can require use of technology outside the EHR. However, huddle reports might also be supported by developing reports populated by data from the EHR. Ideally, internal practice/EHR data should be supplemented with external data where such information completes the patient’s current status. If such electronic access is not possible, workflow should include manual reconciliation by history from the patient.

Action steps and roles

1. Assess the current state of the PVP process across your practice.

Suggested team member(s) responsible: implementation team or QI team.

Understand how the process currently works for all visit types (e.g., scheduled, same day, virtual) in light of your practice’s performance on core and supplemental measures.

Compile existing paperwork and process documentation into one place and talk to MAs and other members of the care team to understand their questions and challenges around the PVP process.

Consider making current-state process maps that communicate the major steps in the PVP process and acknowledge pain points or challenges in the process. Pain points are places where the process is not working well for patients, staff or specific subpopulations or demographic groups for whom your data analysis has revealed equity gaps. In addition, pay attention to places where staff are creating workarounds to the process. The presence of workarounds indicates that the process might need further clarification or refinement to support the care team to reliably implement it.

Your team may find it helpful to compile process maps both for the high-level PVP as detailed in Figure 14 and for more detailed documentation for specific clinical workflows.

 

FIGURE 14: EXAMPLE OF A HIGH-LEVEL PVP WORKFLOW

Figure 6.1 Pre Visit Planning

See the PHMI Care Teams and Workforce Guide Resource 6: Workflow Examples for more information.

 

2. Identify where to update the PVP process to more consistently and reliably address care gaps.

Suggested team member(s) responsible: implementation team or QI team – may include the data manager to assist with identifying patients through EHRs.

Examine where you can further incorporate or streamline your practice’s clinical protocols and standing orders into PVP, including via the PVP checklist, daily huddles and other key clinical workflows.

This may include the following discussion points:

  • Who will initiate the discussion with the patient based on the needs (e.g., primary language) and preferences of the patient. It may be beneficial to have communications coaching or training for staff on how to ask or address difficult questions or conversations.
  • How and when they will plan to have the discussion during the visit.
  • How they will be prepared to address any barriers.
  • What educational materials will be available for use that are relevant to the patient.

Examples and considerations for updating the PVP process are included below.

Clinical guidelines and care gaps: Consider which preventive and maintenance services could be addressed more reliably using PVP, including those in your EHR’s care gap module. The Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care resource provides a more complete list of preventive services for adults and children. Figure 15 provides an example of how your EHR might be able to support flagging any patient overdue for common maintenance services (A1c, LDL, nephropathy, eye exams, and foot exams).

 

FIGURE 15: PVP REPORT DETAILING OVERDUE PREVENTIVE AND MAINTENANCE SERVICES

Pre Visit Planning Report Detailing Overdue Depression Screening

PVP checklist: A generic PVP checklist to be completed by the MA or LVN at least one to three days before the appointment is provided in Figure 16. Most EHRs will have a health maintenance module that identifies what preventive care is due, but a printed or digital checklist provides a starting point for ensuring key steps are not missed.

 

FIGURE 16: PVP PLANNING CHECKLIST

Checklist Domain

Checklist Item


General

  • Reason for patient visit.
  • Check for transportation needs to and from the appointment.
  • Check if there is a need for mobility assistance.
  • Check if interpretation services are needed.
  • Check for cultural, faith-based, or LGBTQIA+-related needs that must be addressed to provide culturally relevant care.

Room readiness

  • Type of exams planned and readiness of room (e.g., microfilaments, diabetes testing materials, etc.).
    • This may also include, during the rooming process, asking the patient to remove their shoes if a diabetic foot exam is required.
  • Specific supplies needed for the patient/procedure.

Medical record review

  • Pertinent labs or imaging results.
  • Recent emergency department or hospital visit records.
  • Special vital signs to be obtained and charted.

Screenings are completed by the patient, results are
documented, and follow-up is completed.

  • Diabetes and/or hypertension screening(s) due.
  • Other health assessments due.

For a more complete list of preventive screenings, see the resource Pre-Visit Planning: Leveraging the Team to Identify and Address Gaps in Care.

Scrub chart for care gaps, preclinic labs and missing information:

This is not an all-encompassing list of what should be included for PVP; instead, it serves as a starting point to address core HEDIS measures.

  • Current labs due (A1c, complete blood count, etc.).
  • Current A1c for patients with diabetes.
  • Last blood pressure reading.
  • Relevant baseline labs.
  • Current urine albumin-to-creatinine ratio (UACR).
  • Diabetic eye exam.

An example chart scrub process led by the MA or LVN as part of PVP for completing open orders is detailed in Figure 17.

 

FIGURE 17: EXAMPLE CHART SCRUB PROCESS FOR OPEN ORDERS

Phmi Chartscrubprocessforopenorders

Daily huddles: Design or redesign the team’s daily huddle so the care team can review prioritized action items for the list of patients scheduled to come and any further follow-up for patients seen in the previous days. Work to incorporate it as part of the regular clinic schedule. For more information, see the PHMI Care Teams and Workforce Guide Resource 4: Daily Huddles Overview and Process.

The Center for Excellence in Primary Care resource on Healthy Huddles includes tools, a video and examples of how pre-visit planning (PVP) flows into the daily huddle process, including a healthy huddle warm-up, which can help MAs prepare for huddles.

Patients requiring special considerations: Ensure that the PVP includes a process to flag for the care team:

  • Patients requiring special attention, such as those with complex needs or recent hospitalizations.
  • Patients who need extended time or additional services during their visit (e.g., translation services, mobility assistance, screenings).

Specific consideration for patients with diabetes: The patient should be contacted one to four days prior to their appointment to ask them to bring in their glucometer and/or readings so that the clinician can review them. Additional steps may be required to prepare for a diabetes management appointment, such as reviewing if the patient has an adequate amount of diabetes management supplies (such as glucose meters, lancets, glucose test strips, etc.) and downloading/uploading the glucometer data if a patient is part of an RPM program. See Key Activity 24: Develop System to Provide Remote Monitoring for more information.

Detailed clinical workflows: Clinical workflows should be updated to describe at which step in PVP or the patient visit a care team member will address a specific gap in care with the patient.

Planning for care after the visit: Effective PVP includes scheduling pre-visit labs and other diagnostics at the end of the current visit, as well as coordinating care and referrals for services not available at the practice. Confirm the patient understands the purpose of any follow-up care. See Key Activity 18: Coordinate Care for more information.

The American Medical Association has an online guide for implementing PVP, which includes forms, templates and other resources.

 

3. Test planned changes to the PVP workflows and support care teams in implementing the workflow.

Suggested team member(s) responsible: implementation team or QI team.

Test and refine important changes to the PVP process with one or two care teams before considering rolling out the change more broadly at the practice.

Implementing the change includes updating documentation and creating a staff training schedule or training refresher for staff to sustain workflow changes. For example, train MAs every six months on the PVP. If they have difficulty, have them retake training with a different highly effective MA and monitor closely until competency in the task is reached.​ Infrastructure should be evaluated to ensure that there is adequate training and staff time to effectively complete this process.

Customizing the EHR: For further streamlining of the process, practices can customize their EHR template to align with PVP workflows. Be sure to account for potential costs associated with the creation of new templates, staff training and IT.

An example of this is Golden Valley Health Centers, which outlined workflows for their staff in relation to medication results based upon patient blood pressure results taken while in the clinic.

 

4. Establish a process to review and update PVP workflow.

Suggested team member(s) responsible: care team with quality improvement manager.

Identify staff responsible for reviewing and updating the PVP process at least annually to incorporate the latest clinical guidelines and check for any workarounds that have developed.