Addressing Gaps in Care
It is difficult, if not impossible, to provide high quality care for patients with chronic diseases without systematically identifying and addressing gaps in care. Without a plan, patients often report that clinicians do not explain things well and clinical teams are left feeling like they've expended a tremendous amount of energy without accomplishing very much.
Based on the Chronic Care Model (for more details, see www.improvingchroniccare.org), planned visits are one way to ensure that the care team reviews each patient's care and identifies and addresses gaps in care. Planned visits are pre-scheduled visits that allow time for the clinical team and the patient to review the patient's progress and address clinical and self-management topics. Planned visits fill the gap left by acute care visits by providing an opportunity for patient education and self-management support.
Another option implemented successfully by Kaiser Permanente Southern California (KPSC) is the proactive office encounter (POE), described in "In the Literature" to the right, below. In order to make each patient encounter as efficient as possible, KPSC developed the concept of the POE as a way to turn each encounter into an opportunity to address preventive screenings and care for chronic conditions. POE utilizes information technology, empowered care teams and structured work flows to address individual care gaps in every outpatient setting. The POE breaks each encounter into three phases-pre-encounter, office encounter and post-encounter-identifies tasks to be completed during each phase and assigns responsibilities for the completion of each task.
Specific pre-visit planning processes that can help improve productivity and enable care teams to be proactive in managing patient care include:
- Daily huddles to identify patients on the schedule who need special services or extra assistance
- Identifying gaps in care that need to be filled and highlighting indicators/results of therapeutic range to be addressed during the visit
- Making sure all ordered test results and consult reports have been received, so treatment decisions can be made during visits and do not require unnecessary (wasteful) follow-up work
Regardless of the approach, planned care has been shown to result in better clinical control of illness, reduction of symptoms, and improvement of overall health and an increase in patient's sense of control over their health. Planned visits may also lead to fewer acute care visits, reduced costs and improved patient satisfaction.
Each section of this newsletter offers resources to improve planned care in your office - from continuing education for your nurses, to simple tools to ensure successful implementation of standardized work flows, to proof of what can be accomplished when these concepts are implemented in a thoughtful manner.
You also can learn more about team-based planned care on the Improving Primary Care website, which contains a variety of samples, templates, and training resources.
1. Agency for Healthcare Research and Quality: Planned Visits
2. Bodenheimer T, Wagner EH, Grumbach K. Improving Primary Care for Patients with Chronic Illness. JAMA. 2002;228(14):1775-9.