Want to take quizzes and track your credits?
At the Marshfield Clinic Minocqua Center, Rick Fossen, MD, FACP, has been working with his nurse, Breanne, in a team-based care model. Breanne uses the electronic health record (EHR) to identify chronic and preventive care needs that are either upcoming or overdue for the patient. For complex patient cases, she involves Leah, the unit coordinator, to assist with scheduling appointments and follow-up care.
To address out-reach panel management, all team members are trained to use an intervention list or “I-list” to identify “in-between” health needs of the practice's entire patient population, such as chronic and preventive services that patients need in-between visits. A team of clinical nurse specialists proactively monitor the I-list and reach out to patients to address any care gaps. The team of clinical nurse specialists also train other care team members at the clinic, such as nurses, medical assistants, and unit coordinators, to effectively manage their own I-lists based on their area's priorities. Nurses, medical assistants, and unit coordinators use their I-lists to reach out to patients to address care gaps and schedule necessary appointments. The unit priorities are identified through localized practice councils comprised of physicians, nurses, medical assistants, unit coordinators, and clinical nurse specialists that report to a quality improvement and patient safety committee.
AMA STEPS Forward® presents actionable, practical toolkits and customizable resources that you can use to successfully implement meaningful and transformative change in your practice or organization. See How it Works
Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.
You currently have no searches saved.
You currently have no courses saved.