July 2015 Newsletter
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.


Additional 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.

On-Demand Continuing Education Webinars for Nurse

Empowered health care teams are
essential to the success of planned care efforts. Continuing education can play an important role in ensuring that members of the clinical team feel comfortable and confident to work at the top of their license.

The Agency for Healthcare Research and Quality has archived webinars for continuing education credits for nurses, nurse practitioners, case managers and educators. The webinars teach participants how to use evidence-based resources in clinical practice and improve patient safety in long-term care facilities. Continuing Education Credits are available for each webinar.
Best Practices Spotlight

In an effort to provide reliable, standardized care for "every patient, every place, every visit, every time," Penn State Hershey Medical Grou p clinics have implemented standard work flows for chief complaints and Proactive Office Encounters (POEs) based on Kaiser Permanente's Proactive Office Encounter  
(Templates here ).

After being debriefed on the standard work flow, nurses were provided with 3X5 color-coded cards covering 11 topics. Cards lay out tasks to be completed at each step of the process (pre-encounter, during office encounter and post-encounter) as well as guidance on which staff should complete tasks.


The cards are intended to ease implementation by providing a quick reference for staff implementing the updated work flows. 

In The Literature


Complete Care at Kaiser Permanente: Transforming Chronic and Preventive Care


Beginning in 2005, regional leadership at Kaiser Permanente Southern California (KPSC) recognized opportunities to further enhance evidenced-based, person-focused care. As a result, KPSC developed and implemented "Complete Care"-a comprehensive delivery system redesign with expanded and integrated clinical information systems, decision support, work flows and self-management support. The development of "Proactive Office Encounters" was an initial step in this effort. To date, Complete Care has been applied to 26 chronic conditions as well as areas of preventive and wellness care in all care settings. Complete Care optimizes the roles of all team members in order to address health needs for each individual during every encounter within the health system.


Implementation of Complete Care at KPSC resulted in an average 13.0% improvement on 51 HEDIS metrics and initiated six years of quality gains at KPSC that outpaced gains in the HEDIS national percentiles for numerous measures. KPSC has continued to build upon its initial success by identifying additional gaps in care and including them on proactive office encounter checklists related to elder care, advance directives, post-hospital care, immunizations, health maintenance and pregnancy care.

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