Pre-Visit PlanningSave Time and Improve Care

1. Outlines how to plan the current patient visit and prepare for the next.

2. Provides answers to common questions about pre-visit planning.

3. Gives guidance to address what you may encounter during implementation.

4. Shares case reports describing how practices are successfully using pre-visit planning.

Quiz Ref IDPre-visit planning involves scheduling patients for future appointments at the conclusion of each visit, arranging for pre-visit lab testing, gathering the necessary information for upcoming visits, and spending a few minutes to huddle and handoff patients. Pre-visit planning can mean the difference between a clinic where a physician and the team are floundering and frustrated, and a clinic that runs smoothly with the capacity to handle any unanticipated issues that arise.

• 1. Reappoint the patient at the conclusion of the visit.

• 2. Use a visit planner checklist to arrange the next appointment(s).

• 3. Arrange for the laboratory tests to be completed before the next visit.

• 4. Perform visit preparations.

• 5. Use a visit prep checklist to identify gaps in care.

• 6. Send patient appointment reminders.

• 7. Consider a pre-visit phone call or email.

• 8. Hold a pre-clinic team huddle.

• 9. Use a pre-appointment questionnaire.

• 10. Hand off patients to the physicians.

Use this calculator to estimate the amount of time and money you could save by implementing pre-visit planning in your practice. Results should be verified for your specific practice and workflows.

Enter the amount of time (minutes) per day spent by physicians and your team on activities that could be eliminated by pre-visit planning.

Pre-visit planning communicates to the patients that the practice is planning ahead in order to make the next patient visit as meaningful as possible.

Practices can plan ahead by scheduling patients for their next visit at the conclusion of each visit, including scheduling any needed pre-visit laboratory testing (plan forward). This saves time and reduces the number of “touches” to set up planned care appointments.

Alternatively, practices that do not have the capacity to hold future laboratory orders may choose to employ a look backward strategy, where a staff person orders laboratory according to an established protocol based on the patient's medications and/or conditions a few days before the next appointment. Although the look backward strategy involves more staff “touches” than the plan forward approach, any amount of pre-visit planning is helpful.

As you consider how to implement pre-visit planning in your practice, you can use this checklist to guide you.

“We think about the patient more inclusively before they come in for their visit so that we can take care of as much as possible at the time of the visit. This prevents work later.”

The visit planner is a checklist that allows the physician to indicate the interval until the next appointment and any associated labs required prior to that visit. It should be quick and convenient to use, requiring no more than a few seconds of physician time. The visit planner checklist can be used by a medical assistant (MA) or other team member who can schedule the appointments and tests indicated by the physician.

By performing lab tests before the visit, the physician and patient can discuss results and management decisions face-to-face. Some organizations arrange for the patient to come for lab testing a few days before the visit. However, others have developed rapid turnaround or point-of-care testing for most tests so they can be performed the same day as the visit with the physician.

Quiz Ref IDRegardless of the approach, the goal is to have the test results available so physicians and patients can discuss the results and make management decisions together during the face-to-face visit, As a result, both the patient and the practice save time as they no longer have to spend time contacting the patient with results after the visit.

“An internal medicine practice in Boston found that pre-visit laboratory testing reduced the number of letters and phone calls for results by more than 80 percent and saved $25 per visit in physician and staff time.”

Quiz Ref IDVisit preparations can be done by the nurse or MA the day before or just prior to the appointment. This will save time and reduce mistakes during the visit. The nurse or MA can conduct the following activities:

1. Review the physician's notes from the patient's last visit as well as notes from other providers who delivered interval care. If any interval care notes or results are not in the patient's record, the nurse or MA can call that office or department to obtain the information prior to the visit.

2. Print copies of laboratory test results, x-rays, or pathology reports to share with the patient. A printed simple list of current medications can be handed to the patient upon check in and medication review can begin in the waiting room. If a patient portal is available, the nurse or MA can later refer the patient to these results.

3. Identify gaps in care that need to be closed, such as immunizations or cancer screenings.

A visit prep checklist or health maintenance screen in the EHR or separate registry provides an overview of the preventive and chronic care needs (e.g., immunizations, cancer screenings, and testing for patients with diabetes). In practices without an EHR or a clinical registry, the team may choose to collect this information manually before each visit. This important step will help the clinical team address any patient needs during the upcoming visit.

Customize this sample visit prep checklist to your practice's unique needs.

Many practices send patients automated reminder letters, emails, phone calls, or text messages a few days before their appointments as it reduces no-show rates. If no automated option exists, these calls can be made by members of the team or letters can be sent directly from the office.

Quiz Ref IDNurses or MAs in some practices also make a pre-visit phone call to their more complex patients, performing tasks such as medication reconciliation and agenda setting on the phone, and then pre-populating the next day's visit note with this information. Other practices email a link for the patient to complete a pre-appointment questionnaire and the patient's responses flow into the next day's visit note. Both approaches save the team and physician time during the clinic session.

“Our providers become unglued if there isn't pre-visit lab.”

Kathy Kerscher, MBA, Team Leader of Operations, Bellin Memorial Hospital

A five- to fifteen-minute daily pre-clinic huddle brings the team together to review and share knowledge about the day ahead. The care team can use this time to announce last-minute staffing or schedule changes, discuss special needs of the patients or team members, and determine how best to share the workload.

During the huddle, the nurse or MA, who performed the pre-visit prep, can tell the physician about an abnormal x-ray result, a complex multi-disciplinary situation, or arrange for an interpreter. This provides an opportunity for the physician to consult with colleagues or other resources prior to the patient's visit.

Provide each patient with a questionnaire to complete before the appointment, either electronically from home or on paper at check-in. The pre-appointment questionnaire allows the team to see what is most important to the patient, and helps the physician plan the visit before entering the room. The pre-appointment questionnaire can include questions that would otherwise be asked during rooming, such as depression screens, pain assessment, smoking status, falls screening, and specific questions associated with the Medicare Annual Wellness Visit.

A printed medication list can be reviewed and edited by the patient while in the waiting room. Patients can highlight which medications need refills or they are not taking. By shifting these questions to the questionnaire, the nurses and MAs have much of the information they need to obtain during the visit, giving them more time to engage with patients.

Customize this pre-appointment questionnaire to your practice's unique needs.

The nurse or MA will often learn important information about the patient during the rooming process. A brief one-minute handoff to the physician can save time in the exam room by helping the physician focus the appointment to meet the patient's needs and expectations. The handoff also makes patients aware that their care team is working together on their behalf. For example, the physician may say, “The nurse mentioned that you've been worried about side effects from your cholesterol medication—please tell me more.” The team will quickly see the importance of their initial discussions with patients.

A warm handoff is when the transfer of care between two members of the health care team is conducted in person and in front of the patient (and family if present).¹ This exchange can also be used to alert the physician to the emotional status of the patient so the physician can better calibrate their initial tone to match their patient's needs. An example of this could be if the nurse says, “Her husband is in the hospital and she is worried and upset.”

The strategies, tools and resources in this module can assist you in adopting a pre-visit planning approach that fits your practice's specific needs. Quiz Ref IDPre-visit planning will help your practice benefit from improved communication with patients, streamlined scheduling of appointments, and enhanced care team efficiency during all patient visits.

You can measure the impact of pre-visit planning using this pre-visit planning measurement guidebook. It is designed with a quality improvement framework that will allow you to see positive changes in your operational efficiency.

re-appointre-appoint: To schedule any follow-up appointments for patients at their current visit.standing ordersstanding orders: A protocol-driven approach for providing care, such as established procedures for renewing prescriptions and ordering laboratory tests or health screenings. State laws and regulations may address to whom and what can be delegated by standing order.warm handoffwarm handoff: Physically transitioning patient care from clinical support staff to the physician during the patient visit.in-reach approachin-reach approach: Planning in advance so that gaps in care are closed at the time of each face-to-face visit.outreach approachoutreach approach: Occurring outside the medical setting.