Pre-Visit Planning:

Leveraging the Team to Identify and Address Gaps in Care

©️ 2024 Kaiser Foundation Health Plan, Inc.

Pre-visit planning can identify and address gaps in care for patients who are physically present at the clinic. This tool is focused on identifying and addressing preventive and health maintenance gaps in care, leveraging a team-based approach.

Leverage team-based care and the electronic health record (EHR) to improve efficiency and minimize or eliminate paperwork as much as possible. Think about all the tasks involved and whether one needs a medical license to do it. If not, consider delegating that task to someone else on the care team besides the clinician. For example, one does not need a medical license to identify when patients are due for immunizations and to administer them, provided these are within the scope of practice for the individual and are an agreed upon clinic protocol.

These are not recommendations for care due; it is a starter list from which to choose what is right and doable at a given organization. High-functioning medical homes commit to identifying and addressing all gaps in care – chronic and preventive – regardless of the visit reason. This may be an aspirational goal to work towards. Actions to take to address all gaps in care should be very clear. The table below includes examples that can be customized to any practice. Add checklist items for special populations, such as newborns or pregnant patients.

Recognizing that there are reasons this may not work for all practices, a few suggestions are:

  • Have someone on the care team complete a chart review of patients coming in for the day. This is sometimes called “scrubbing the chart” or “chart prep.” Make notes of the gaps in care – chronic care and preventive – for each patient. This takes time upfront but can ultimately be a big timesaver for both the practice and patient alike. It also can reduce the time and effort to conduct outreach to remind patients of services that are due after they leave the clinic.
  • During the huddle, have the care team look at each patient's electronic chart together. Instead of noting what care is due on the paper huddle sheet, clarify what needs to be done to close the gaps in care for each patient – if the checklist is not already quite clear about these steps.
  • Get standing orders and workflows in place to empower medical assistants (MAs) and nurses to enter orders (that may need to be signed by a licensed clinician) for care that is due prior to the patient's arrival and to facilitate or coordinate other aspects of closing gaps in care before, during and after the visit.

When engaging in pre-visit planning, many organizations include advising adult patients to bring their medications in a bag; having patients complete imaging, lab and other tests prior to their visit; ensuring that hospital and referral notes and results are in the chart; preparing rooms with equipment that may be needed for procedures; accommodating those with special needs (e.g., patient who needs an interpreter, disabled person, others who need special accommodations, etc.); gathering information or records for new patients; and more.

These are not care recommendations; any pre-visit planning checklists or activities must be reviewed and endorsed or approved by medical staff. Pre-visit planning checklists must be updated on an ongoing basis and at least annually as guidelines change and new evidence emerges.

COMMON PREVENTIVE AND HEALTH MAINTENANCE SERVICES

Updated January 1, 2024


Services Due
Population
Recommendation Owner
Examples of Possible Actions (These Are NOT Recommendations)

Adverse childhood experiences screening
Children and adolescents ages zero to 19; adults


MA/nurse: administer screening tool to caregiver (if patient is zero to 12 years of age) or to patient (if 13 years of age or over); advise clinician of positive screens

Anxiety and anxiety disorders screening
Adults 64 and under (including pregnant and postpartum persons); children and adolescents ages eight to 18 years

U.S. Preventive Services Task Force (USPSTF)
MA/nurse: administer screening tool; advise clinician of any positive screens

Breast cancer screening

Women ages 50 to 74: every two years

This guideline from 2016 is currently under review.

MA/nurse: pend an order (or order and schedule if standing order) if due and patient agrees; notify clinician if patient declines

Clinician: document informed consent if patient declines

Cervical cancer screening

Women ages 21 to 65 years: every three years (or, for women ages 30 to 65, every five years with cytology [Pap] and negative human papillomavirus (HPV) test

This guideline from 2018 is currently under review.


MA/nurse: schedule patient for Pap if due

Chlamydia and gonorrhea screening
Sexually active women ages 24 years or younger; women age 25 and older who are at increased risk for infection


MA/nurse: ensure that chlamydia and gonorrhea test is performed in population of focus

Colorectal cancer screening
Adults 45 to 75 years of age

MA/nurse: notify clinician for discussion of options (e.g., colonoscopy, sigmoidoscopy, stool-based testing)

Clinician: document informed decision-making if patient declines

Dental caries prevention
Children younger than five years: fluoride varnish; children starting at age six months whose water supply is fluoride deficient: fluoride supplementation


Clinician (or other trained care team member): apply fluoride varnish and prescribe fluoride supplementation as per guidelines

Depression and suicide risk screening
Adults and adolescents ages 12 and older, including pregnant and postpartum people

USPSTF and and American Academy of Pediatrics (AAP)
MA/nurse: administer screening tool; advise clinician of any positive screens

Diabetes and prediabetes screening
Asymptomatic adults ages 35 to 70 years who are overweight or obese


Leverage team-based care where possible

Health-related social needs screening
All adults


MA/nurse: administer screening tool; advise clinician of any positive screens

Healthy diet and physical activity counseling

Overweight or obese adults with additional cardiovascular disease risk factors

This guideline from 2018 is currently under review.


Defer to clinician and patient

Hepatitis B screening
Adolescents and adults at increased risk; pregnant people at first prenatal visit


Leverage team-based care where possible

Hepatitis C screening
Adults ages 18 to 79 years


MA/nurse can see if done and pend order if needed (or order via standing order)

HIV screening

Pregnant people; people ages 15 to 65 years; younger adolescents and older adults at increased risk

This guideline from 2019 is currently under review.

MA/nurse: discuss HIV testing and recommendations for population of focus

MA/nurse: pend an order (or order via standing order) if not already in chart

Hypertension screening (or elevated blood pressure screening for children)
Adults 18 and older without known hypertension; asymptomatic pregnant persons; children ages three and up

USPSTF and AAP

MA/nurse: check office blood pressure measurement as part of vital signs; for adults, alert clinician if >140/90

Intimate partner violence screening

People of childbearing age

This guideline from 2018 is currently under review.


MA/nurse: ask screening questions; document in EHR; notify clinician of positive screen

Latent tuberculosis risk assessment and screening
Adults at increased risk; children

USPSTF and AAP
Leverage team-based care where possible

Lung cancer screening
Annual screening in adults ages 50 to 80 years who have a 20-pack-per-year smoking history and currently smoke or quit within the past 15 years


MA/nurse: identify those in the population of focus for screening and notify clinician

Obesity screening and weight loss counseling

Children and adolescents ages six and older; adults

This guideline from 2017 is currently under review.


MA/nurse: obtain accurate height and weight and offer or refer to comprehensive, intensive behavioral intervention

Osteoporosis screening

Women ages 65 years and older; younger postmenopausal women with increased risk

This guideline from 2018 is currently under review.


MA/nurse: advise clinician if due for osteoporosis screening; schedule per clinician order

Perinatal depression preventive counseling

Pregnant and postpartum persons who are at increased risk for depression

This guideline from 2019 is currently under review.


Clinician: assess and document risk; provide counseling if indicated

Sexually transmitted infection counseling
All sexually active adolescents and adults who are at increased risk


Clinician: assess and document risk; provide counseling if indicated

Skin cancer counseling
Ages 6 months to 24 years with fair skin


MA/nurse: provide counseling; provide educational materials

Statin preventive medication
Adults aged 40 to 75 years with one or more cardiovascular risk factors and an estimated 10-year cardiovascular disease (CVD) risk of 10% or greater


Leverage team-based care where possible

Syphilis infection screening

All pregnant women; adolescents and adults at increased risk of infection

This guideline from 2018 is currently under review.


Leverage team-based care where possible

Tobacco use counseling and interventions
Ask all adults, including pregnant people, about tobacco use

MA/nurse: document tobacco use; notify clinician if tobacco user

Clinician: advise to stop; provide behavioral interventions; provide pharmacotherapy for cessation to nonpregnant adults.

Tobacco use interventions: children and adolescents

School-aged children and adolescents who have not started tobacco use

This guideline from 2020 is currently under review.


Clinician: provide interventions, including education or brief counseling, to prevent initiation of tobacco use

Unhealthy alcohol use screening and counseling
Adults 18 and older, including pregnant women

USPSTF – also aligned with Screening, Brief Intervention and Referral to Treatment (SBIRT)

MA/nurse: ask screening questions and document responses in EHR; if positive, notify clinician

Clinician: provide brief behavioral counseling

Unhealthy drug use screening
Adults 18 and older


MA/nurse: ask screening questions and document responses in EHR; if positive, notify clinician

Vision and hearing acuity screening
Ages three to five years


MA/nurse: complete and document visual acuity testing; notify clinician of any deficits

Immunizations for children
Birth through 18 years
Centers for Disease Control and Prevention (CDC)/AAP

MA/nurse: identify immunizations due per AAP schedule; pend order (or order via standing order), administer and document per clinic protocols

Immunizations for adults
Adults 19 and older
CDC

MA/nurse: identify immunizations due per current CDC schedules; pend order (or order via standing order), administer and document per clinic protocols

Additional Preventive and Health Maintenance Services for:

Children

Per USPSTF:

  • Age-specific behavioral, social or emotional screening.
  • Developmental screening and autism spectrum disorder screening.
  • Hearing acuity screening.
  • Vision acuity screening– also aligned with USPSTF.
  • Lead poisoning assessment and screening – in alignment with the Standard of Care on Screening for Childhood Lead Poisoning from the California Department of Public Health.
  • Other age-specific procedures noted in periodicity schedule.

Pregnant People

Per USPSTF:

  • Aspirin use to prevent preeclampsia.
  • Healthy weight and weight gain in pregnancy counseling.
  • Gestational diabetes test.
  • Breastfeeding interventions and assistance.
  • Asymptomatic bacteriuria test.
  • Folic acid supplementation intervention.
  • Rh(D) incompatibility test.

Patients With Diabetes

Per CDC:

  • Hemoglobin A1c test.
  • Diabetic eye exam.
  • Diabetic foot exam.
  • Urine albumin-to-creatinine ratio (uACR) test.

Patients With Hypertension

Taken from a 2017 report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines:

  • Basic testing: fasting blood glucose; complete blood count; lipid profile; serum creatinine with estimated glomerular filtration rate (eGFR); serum sodium, potassium, calcium; thyroid-stimulating hormone; urinalysis; electrocardiogram.
  • Optional testing: echocardiogram, uric acid, urinary albumin-to-creatinine ratio.

Additional Preventive Services for Specific Populations

Per USPSTF:

  • Abdominal aortic aneurysm (AAA) screening for males ages 65 to 75 who have ever smoked.
  • HIV preexposure prophylaxis for adolescents and adults who are at increased risk of HIV acquisition.
  • Falls prevention for community-dwelling adults ages 65 years and older who are at increased risk for falls.
  • Breast cancer gene (BRCA) risk assessment and genetic counseling/testing for women with a personal or family history of breast, ovarian, tubal or peritoneal cancer, or an ancestry associated with breast cancer gene (BRCA1/2) mutation.

Tips for Behavioral Health Screening

  • Train and support staff to feel comfortable administering behavioral health screeners. Unlike other preventive health screens, many of the tools require numerous questions and cover potentially stigmatizing topics. Provide language to aid staff in normalizing the asking of such questions and create opportunities for staff to role-play administering such questionnaires to gain comfort and experience.
  • Research shows that behavioral health questionnaires are reliable and valid when administered in person, over the phone or electronically.
  • Trauma-informed practices include strategies such as asking permission from patients before administering behavioral health screening tools.
  • Consider adjustments to the screening schedule for those with diagnosed mental health conditions. Examples include forgoing a Patient Health Questionnaire-2 for those with depression and annually (or more frequently) administering the Patient Health Questionnaire-9.

References and Resources