Adults Living with Chronic Conditions Guide

Methods to Expand Access to Chronic Care

1. Use Technology to Expand Access to Care

Maximize the patient portal to boost access to care

• Portals allow patients to communicate with their care teams and can also be a powerful tool for checking in about chronic conditions without requiring an in-person visit. For example, the portal can be used for patients to update clinicians on their home blood pressure or blood sugar values, or as part of a formal remote monitoring program. See Key Activity 22: Develop System to Provide Remote Monitoring for more information.
• The portal can also allow patients to more efficiently request/schedule appointments for chronic care follow-up. For example, Golden Valley Health Centers uses their electronic health platform to allow self-scheduling for same-day appointments. Health educators support patients and families to develop digital literacy to enable effective use of the patient portal.

Provide telehealth appointments as a routine option for chronic conditions follow-up, including both telephone and video visits.

• Telehealth appointments allow patients much more flexibility, especially when combined with effective patient home monitoring of blood pressure and blood sugar.

Actively manage the appointment wait list to maximize use of appointment slots, such as through daily or twice-daily care team huddles.

• Scheduling staff can participate in care team huddles by reviewing the schedule in real time, forecasting the likely rate of missed appointments, and prompting the front desk to call patients on the wait list and/or open slots to patients who can use the patient portal to schedule a same-day appointment.
• Peer example: Petaluma Health Center clinic managers review the schedule in real time and ensure no show slots are allotted to same-day appointments.

2. Offer chronic conditions check-ups, education and support through periodic health fairs and community outreach in conjunction with other needed services.

This can include services such as vaccine clinics, food distribution or food pharmacy services. See Key Activity 20: Addressing Food is Medicine Needs of Individuals with Chronic Conditions for more information about partnering with community providers for food and nutrition. Social media can also be used to reach families by sharing information in easy-to-understand language about chronic conditions, health fairs, and partnerships with food pharmacy services or community-based services.

• Peer example: Santa Rosa Community Health hosts food pharmacy distribution, where health educators connect with families to answer questions, prompt families to make appointments, and assist families to register on the patient portal.
• Implementation Tip: Practices should go to where the people in their community are. The Cut Hypertension Program from UCSF is a great example of how clinical care can be expanded. This blog post and presentation provides more information about the program.

3. Expand Clinic Hours Available for Chronic Care

Provide a weekend clinic.

• Saturday clinics are especially important for patients with strict weekday work schedules. Sample format:
  • Hold a weekly clinic session from 9 am –1 pm on Saturdays.
  • Staffed by a single care team, comprising one or two PCPs with a medical assistant or Licensed Vocational Nurse (LVN).
  • Each provider would provide well-care visits slots for 10-12 of their own patients for chronic care/routine follow-up and have additional slots for urgent appointments, during which uncontrolled blood pressure and blood sugar should also be addressed.

Extend the afternoon clinic once or twice per week into the evening, (ex., with the last patient seen at 7:00pm for a clinic end time of 7:30pm). Care teams can align staff by arranging a PCP to provide a session and a half of patients alongside nursing staff, particularly those who work 3-4 ten-hour shifts per week.

4. Ensure activities needed to manage chronic conditions are efficiently incorporated into urgent care visit appointments to address blood pressure/blood sugar control and close care gaps.

This includes normalizing a culture among clinicians and staff to address hypertension and diabetes control at any type of visit or contact with a patient, even if seemingly unrelated to the reason the patient is in the clinic. See Key Activity 8: Develop or Refine and Implement a Pre-Visit Planning Process for more.

5. Utilize care team members to provide chronic condition support as alternatives or adjuncts to primary care provider visits.

Consider using a team-based model of care in which teams are encouraged to work at the top of the license and in an expanded capacity. This improves patient outcomes and the care team’s efficiency, all while reducing physician burnout. This is especially important when access for primary care providers is limited.

Examples include:

• Registered nurses providing basic chronic condition follow-up visits, which can include patient education, lifestyle change support, self-monitoring teaching, and basic medication titration (with appropriate clinician-approved protocols in place).
• Clinical pharmacists providing chronic condition follow-up visits.
• Behavioral health, nutritionist, community health workers, or health coach roles to support lifestyle change and chronic condition self-management

CMS’ Next Steps in Team Based Care provides steps and things to consider when implementing a team-based care model. An example of a team-based care structure is represented in PHMI’s Care Team Profiles. Additionally, a case study from Saban describes how they operationalized team-based care with their Pharmacist Managed Diabetes and Hypertension Clinic.

See the resources section below for an example standardized procedure for nurse-led hypertension visits.