Preventive Care - Key Activity 8

KEY ACTIVITY #8:

Refine and Implement a Pre-Visit Planning Process


 

This key activity involves the following elements of person-centered population-based care: operationalize clinical guidelines; pre-visit planning and care gap reduction; care coordination; address social needs.

Overview

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

  • At the end of the current visit to ensure the patient understands any actions they need to take and to schedule any follow-up.
  • Prior to a scheduled appointment, 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 PCP.

The average visit time for U.S. primary care providers is 13 to 24 minutes, [1]and many patients come to these visits with multiple needs. Pre-visit planning works towards optimizing a team-based approach in preparation for these short primary care visits so patients receive comprehensive care in alignment with the latest clinical guidelines and their own preferences.

Pre-visit planning allows for better coordination of care and works to maximize opportunities to address multiple health-related needs. 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, pre-visit planning 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 include information regarding each patient’s known social needs and incorporate your practice’s process for screening and responding to social needs. Social needs may be screened by an MA and any outstanding questions reviewed with the team or social worker in the daily huddle. 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.

Pre-visit planning draws upon similar technical enablers as care gap reporting and likewise can be facilitated at the individual patient level and at the level of groups of patients coming for care by a specific team 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 and care coordination (See Appendix E: Guidance on Technological Interventions.)

Individual patient-level pre-visit planning 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. Pre-visit planning might also include use of patient-facing applications, such as portal reminders, questionnaires, and self-completed screenings and assessments, which ideally would be available to the provider and care team in the EHR.

Engagement of the expanded care team in pre-visit planning 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, but might also be supported by developing reports populated by data from the EHR. Ideally, internal practice and EHR data should be supplemented with external data where such information completes the patient’s current status. If such electronic access is not possible, the workflow should include manual reconciliation by history from the patient.

 

Figure 15: An example of how technology can help with pre-visit planning.

 

Action steps and roles

1. Assess the current state of the pre-visit planning (PVP) process across your practice.

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

  • This step begins by working to understand how the process currently works based on your practice’s performance on core and supplemental measures.
  • Compile existing paperwork and process documentation into one place and talk to medical assistants and other members of the care team to understand their questions and challenges around the pre-visit planning process.
  • Consider making current-state process maps that communicate the major steps in the PVP process and acknowledge pain points or kinks in the process. Pain points are places where the process isn’t working well for patients, staff or specific subpopulations or demographic groups for which 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 for both the high-level pre-visit planning, as detailed in figure 6.1 of the PHMI Care Teams and Workforce Guide Resource 6: Workflow Examples, in addition to more detailed documentation for specific clinical workflows. Understand which clinical workflows and care gaps are currently addressed through the PVP process and work to understand what gets in the way of the team reliably addressing these care gaps.

FIGURE 16: EXAMPLE WORKFLOW FOR PRE-VISIT PLANNING (PVP).

Picture1

 

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

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.
  • How and when they will plan to have the discussion during the visit.
  • How they will be prepared to address any barriers.
  • Educational materials available for use that are relevant to the patient.

Clinical guidelines and care gaps: Consider which preventive and maintenance services could be addressed more reliably using PVP and include 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.

PVP checklist: A generic PVP checklist is to be completed by the MA or LVN at least one to three days before the appointment is provided in Figure 17. 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 aren’t missed.

 

FIGURE 17: PVP PLANNING CHECKLIST ITEMS TO ADD FOR ADULT PREVENTION

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., speculums available).
  • Specific supplies needed for the patient or procedure.

Medical record review

  • Pertinent labs or imaging results.
  • Recent emergency department (ED) 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.

  • Cancer 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, but instead serves as a starting point to address core
HEDIS measures.

  • Cervical cancer screening (Pap smear) due if the patient has a cervix.
  • Breast cancer screening (mammogram) due if female or receiving estrogen therapy.
  • Colorectal cancer screening due (e.g., FIT or colonoscopy). 

An example chart scrub process led by the MA or LVN as part of PVP for completing open orders is detailed in Figure 18.

 

 

FIGURE 18: EXAMPLE CHART SCRUB PROCESS FOR OPEN ORDERS.

Phmi Chartscrubprocessforopenorders

 

Putting it all together: Leveraging team-based approaches to address screening for cervical, colorectal and breast cancer

Pre-visit planning checklists may be created by the multidisciplinary team, authorized by the medical team, and carried out by relevant health center staff. The list below provides examples of possible actions that care team members can take to support providers and to advance population health management for both in-person visits or outreach attempts to identify and address gaps for cervical, colorectal and breast cancer screening.

For breast, cervical and colorectal cancer, MAs or nurses (or others on the team) can:

  • Advise the patient they are due for the screening.
  • Provide patient education on the benefits of completing the screening.
  • Outline screening options for the patient.
  • Enter orders into the EHR in accordance with standing orders (see Key Activity 5: Develop and Implement Standing Orders).
  • Assist or refer patient to ensure insurance or other program coverage and to advise of any potential out-of-pocket costs.
  • Schedule patient, if possible. If not, provide information to the patient to schedule and set a reminder to call patient to ensure they were able to get scheduled.
  • If a patient declines, document accordingly, including why the patient declines, and notify the provider to have further discussions and to document that the patient declines after informed consent.

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. For more information, see PHMI Care Teams and Workforce Guide Resource 4: Daily Huddles Overview and Process.

The Centers for Excellence in Primary Care resource on Healthy Huddles includes tools, a video, and examples around how pre-visit planning flows into the daily huddle process, including a “Healthy Huddles” 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 chronic conditions, complex needs or recent hospitalizations.
  • Patients who need extended time or additional services during their visit (e.g., translation services, mobility assistance, screenings).

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 forward for care after the visit: Effective PVP includes scheduling pre-visit labs and other diagnostics at the end of the current visit and coordinating care and referrals for services not available at the practice (see Key Activity 13: Coordinate Care). Confirm the patient understands the purpose of any follow-up care.

The American Medical Association (AMA) has an online guide for implementing pre-visit planning, 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 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.

 

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.

Implementation tips

  • If the previous visit noted the need for laboratory testing for the next visit, the assigned team member should check to see if the testing has been completed. If not, the patient should be contacted to discuss this with the patient and recommend testing prior to the visit. This maximizes the value of the visit.
  • Pre-visit questionnaires, sent electronically or by mail in advance of the visit or completed in the waiting room, can provide additional information that the care team can review prior to the patient’s visit.
  • See also Appendix D: Peer Examples and Stories from the Field to learn about how others are implementing this activity.

Endnotes

  1. Time physicians spent with patient U.S. 2018 | Statista [Internet]. Statista. Statista; 2018. Available from: https://www.statista.com/statistics/250219/us-physicians-opinion-about-their-compensation/