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.
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