System Changes and Interventions: Planned Care

1. System Changes and Interventions:Planned Care Mike Hindmarsh Improving Chronic Illness Care, a national program of the Robert Wood Johnson Foundation IDCOP National Summit Chicago May 13-15, 2002

2. Delivery System Design • Define roles and delegate tasks amongst team members. • Use planned visits to support evidence-based care. • Build effective case management skills into practice • Assure continuity by the primary care team. • Assure regular follow-up.

3. Roles in Team Care

4. Group Visits: A Primer • Patients brought in by clinically relevant groups • Patients can receive: • Specialty service as needed/available • One-on-one with medical provider • Medication counseling • Self-management support training • Social support • Multiple Models for Group Visits

5. What is a Planned Visit? • A Planned Visit is an encounter with the patient initiated by the practice to focus on aspects of care that typically are not delivered during an acute care visit. • The provider’s objective is to deliver evidence-based clinical management and patient self-management support at regularly scheduled intervals without the “noise” inherent in the acute care visit.

6. What does a Planned Visit look like? • The provider team proactively calls in patients for a longer visit (20-40 minutes) to systematically review care priorities. • Visits occur at regular intervals as determined by provider and patient. • Team members have clear roles and tasks. • Delivery of clinical management and patient self-management support are the key aspects of care.

7. How do you do a Planned Visit? You Plan It!

8. Step One: Example Senior Care Polypharmacy • Choose a patient sub-population, e.g., all patients >75 on five or more medications • Have programming support person or pharmacy generate list of patients and medications • MD reviews list for patients at highest risk (see handouts)

9. Step Two: Patient Outreach • RN/LPN/MA checks to see if patient is on any registries • Have PCR call patient and explain the need for planned visit • Allow patient to choose day and time for visit • Ask patient to bring in bag of all medications they are taking (including OTCs and herbals)

10. Step Three: Preparing for the Visit • RN/LPN/MA prints any relevant patient summaries from registries and attaches to front of chart • MD reviews medications prior to visit, and consults with pharmacy as needed

11. Step Four: The Visit • Review patient’s medication regimen • Identify and eliminate unnecessary drugs • Adjust remaining medications as needed • Problem solve adherence issues with patient • Create an patient action plan • Schedule follow-up

12. Follow-up • Does not need to be in-person visit (use phone, email) • Check adherence to action plan • Problem solve as needed • Schedule additional follow-up as needed