Chronic Conditions - Key Activity 6


Incorporate Chronic Disease Management Into Sick Visits


This key activity involves all seven elements of person-centered population-based care: all visits; operationalize clinical guidelines; behavioral health integration; address social needs.


Ensuring that activities needed to manage chronic conditions are incorporated into sick visit appointments expands access to care and facilitates a “whole-person care” approach. This creates opportunities to build interventions that are responsive to patients’ needs and preferences for engaging in the health system. It also provides opportunities to see if patients are up-to-date on condition-monitoring lab work and if nonacute visits should be scheduled.

Incorporating well-care visits into sick visits meets the patient where they are and maximizes the value of their time in the clinic. Many patients will only seek care when they require a sick visit. Therefore, it is highly valuable to incorporate routine care into sick visits.

Patients and families with lower socioeconomic status are likely to benefit from the ability to access preventive care when they are able to visit the clinic. For example, patients who balance competing demands may struggle to keep scheduled appointments. They would benefit from having the opportunity to engage in wellness care during a sick visit. Due to financial constraints, patients may prioritize urgent care over routine or preventive care.

Clinical decision support to prompt the care team to attend to preventive care during all visits is an effective strategy. Ideally, this would be positioned to be available to the extended care team and not restricted to the medical clinician. Prompting strategies can be reinforced through the availability of care guideline-driven order sets and standing orders available in the EHR. See Key Activity 9: Develop and Implement Standing Orders for more information.

Care quality and care gap reports that are analyzed against visit history can be utilized to track progress by clinician and care team in leveraging sick visit opportunities to meet guidelines.

(See Appendix E: Guidance on Technological Interventions.)

Action steps and roles

Below is a sequence of steps that practices can use to leverage visit activities.


1. When scheduling an appointment, consider providing longer appointment times for sick visits that will incorporate wellness activities.

Suggested team member(s) responsible: Clinic administration, QI lead

The office staff who schedule sick visits can be helpful in assisting clinical staff to identify patients who are overdue for wellness care. Additionally, office staff can use patient messages, medication refill requests and phone calls as touchpoints to screen for preventive care needs/opportunities.


2. Use pre-visit planning (PVP).

Suggested team member(s) responsible: QI lead, care team lead and frontline staff.

Use a PVP process that includes a pre-visit checklist, data from registries/care gap reports and a staff huddle to identify which patients with scheduled sick visits would benefit from the inclusion of chronic care management activities. The team should determine priority chronic care management activities to include for each sick visit. See Key Activity 10: Develop or Refine and Implement a Pre-Visit Planning Process for more information.


3. Empower rooming staff to engage patients in the decision to do the care activity.

Suggested team member(s) responsible: director or care team lead.

Staff may be required to make a real-time decision about whether to go ahead with addressing wellness needs – keeping in mind that a visit may be lengthened and/or raise topics that patients may not be prepared to tackle when feeling unwell. Care team leaders can empower rooming staff to offer opportunities for patients to engage in wellness care and express the importance of patients’ own priorities.


4. Test new and adapted practices and processes to develop improved workflows and standard protocols for implementing management of chronic conditions during sick visits, focusing first on prioritized areas for improvement.

Suggested team member(s) responsible: QI lead with frontline staff, patients and their families.

Implementation tips

  • Consider how your existing technology can be leveraged to automate or partially automate the steps in this key activity (e.g., EHR, automated survey mailers/email platforms).
  • Gain input from care teams while implementing this measure. Work with clinical staff to implement this activity in a way that optimizes workflows and supports best patient care.