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Outlines how to plan the current patient visit and prepare for the next.
Provides answers to common questions about pre-visit planning.
Gives guidance to address what you may encounter during implementation.
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.
A reference for implementing the 10 steps of 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.”
Amy Haupert, MD, Family Medicine, Allina Medical Clinic, Cambridge, MN
Our schedules are open only a few weeks in advance. How can we adopt pre-visit planning?
For practices that do not schedule appointments months in advance, a reminder file can be used to schedule follow-up visits and laboratory test orders and to prompt the team to contact patients closer to their follow-up visit dates.
Can I use pre-visit planning with the open-access scheduling approach?
Yes, you can use pre-visit planning with open-access scheduling. The team can use a reminder file to schedule follow-up visits and associated laboratory tests and then contact patients closer to the ideal follow-up visit date.
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.
Can you provide an example of when to use the visit planner checklist?
Consider a patient who has diabetes, hypertension, and hypothyroidism who will be due for their annual comprehensive care visit in three months. During the current visit, the physician uses the visit planner checklist and indicates the appointment interval and type: “Three-month physical exam” and also checks “diabetic panel, TSH, Na, K, creatinine and mammogram.”2- 5 A member of the physician's team can then schedule the patient's annual visit, the indicated laboratory tests, and the mammogram.
Our physicians are overwhelmed by the process of selecting a diagnosis code for each test, a process that can add several minutes to each appointment. Do you have any suggestions?
When creating the visit planner checklist, pair each test with the two or three most frequently used diagnosis codes for that test. The physician can then easily check the appropriate diagnosis code for that patient, alleviating the need in most circumstances to search through a longer list of codes.
For example, the default ICD-10 code might be D64.9 (anemia) for a hemoglobin workup with the option of checking for R53.83 (fatigue) or for R19.5 (blood in stool). If the hemoglobin is ordered for another diagnosis, a search can be undertaken for the correct ICD-10 code, but for most patients the correct ICD-10 code will be one of the three options provided next to the test name on the visit planner. Some practices work with their IT department and/or EHR vendor to create an electronic version of the checklist.
Our physicians commonly order the same bundles of tests. Can the visit planner help with this?
Yes. You can create “order sets”, or tests that are bundled based on conditions. This simplifies the ordering process and reduces the likelihood that laboratory tests are missed. For example, an order set for diabetes provides the diagnosis code and orders an entire panel of relevant tests — HgbA1c, lipid profile, urine albumin creatinine ratio, and creatinine blood test — with a single checkmark or click.2
As a physician I have had the experience of re-appointing a patient in three months, only to later discover the patient was due for their annual wellness visit and mammogram in four months. To avoid this scheduling issue, I spend a lot of time searching through the medical record for the dates of these past services. Do you have any suggestions?
It is helpful if the visit planner checklist also includes key information about the dates of the patient's previous annual appointment and any upcoming appointments and laboratory tests. This allows the physician to place the current visit in the context of the patient's other conditions or necessary tests. In this situation, the physician would see that the patient was due for an annual appointment in four months and would schedule the follow-up for diabetes at the same time. Some IT departments and/or EHR vendors create a program that automatically populates this information into the visit planner while other practices plan for other team members to add this information to the checklist manually before the appointment.
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.
Before computerized order entry our physicians ordered the next visit's labs at the conclusion of each visit. Now our organization requires that all test orders done within a visit encounter be entered by the physician. Our physicians don't have the extra two to three minutes per appointment to do this. How can we address this challenge?
Some practices have responded to this type of policy by ordering pre-visit testing outside of the visit encounter. With this approach, nursing staff contact the patient one week before their next appointment and arrange the necessary laboratory tests using standing orders based on the patient's clinical conditions and medications. Another solution could be using a team documentation care model, in which a team member supports the physician during the encounter by entering requested orders and aiding with documentation during 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.”
J. Benjamin Crocker, MD, Internal Medicine, Ambulatory Practice of the Future, Boston, MA
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:
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.
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.
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
“Our providers become unglued if there isn't pre-visit lab.”
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.
Should I scan the pre-appointment questionnaire into the EHR?
It is not necessary to maintain a copy of the completed pre-appointment questionnaire. It is a worksheet to facilitate discussion during the visit. Important information from the questionnaire can be recorded in the visit note.
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.”
I like the idea of a handoff. However, I don't always see my MA between patients. She is often in a different room when I am ready to attend to the next patient. How can we address this?
There are innovative ways to hand off patients. First, the MA can brief the physician about several patients at once. This way, if the MA is in a different room when the physician is ready to meet the next patient, the physician is already prepared. Second, the MA can hand off information by listing key information in the patient's chart. A verbal handoff is preferable; however, a short note is still beneficial.
Do I need to hire more staff to implement pre-visit planning?
Not necessarily. Overall, pre-visit planning saves staff time because less time is spent looking for information during the visit and reporting results post-visit. Practices that have success with pre-visit planning often have a 1:1 physician to support staff ratio. That team member is able to save time through effective pre-visit planning.
We have a registry that identifies patients' prevention and chronic care needs as they come due. Why should we address these needs at a visit?
Many practices use the in-reach approach within the medical setting as the primary method for addressing prospective care needs. This is typically done at the annual comprehensive care visit and reserves the outreach approach for patients who were missed in the in-reach approach. In-reach is the most efficient approach.
Practices that exclusively use an outreach approach will spend more time completing administrative tasks in the long-term and may end up asking patients to come in for multiple visits when their needs could have been met in one visit. However, outreach is useful as a tool to close gaps in care for patients who have missed annual appointments or preventive care milestones.
Our physicians and staff are overwhelmed. How can we find time to implement pre-visit planning?
While it may sound overwhelming to implement a new process, successful pre-visit planning can enhance teamwork and operational efficiency. Some practices save an hour or more of physician and staff time per day with pre-visit planning.
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.
Disorganized visits can be stressful for everyone: patients, the care team, and physicians.
Having all needed information available ahead of the appointment minimizes trips in and out of the room as well as disruptions in patient flow to create a healthier and happier work environment.
Avoid being caught off guard by unexpected patient agenda items.
Pre-visit planning reduces the chance the team will be caught off guard by a patient's unexpected agenda item. For example, if the patient indicates on a pre-appointment questionnaire that the main purpose of his or her visit is to get help with insomnia, it is less likely the physician will get to the end of the appointment only to learn that the patient's main concern, difficulty sleeping, had not yet surfaced.
Seek to close potential gaps in patient care both during and before the face-to-face appointment.
Pre-visit planning provides an opportunity to close gaps in a patient's care. During visit prep, for example, the nurse or MA determines if a patient is due for any immunizations or a colon cancer screening. Using established protocols, the nurse can close these types of gaps before the physician portion of the visit begins.
Close the loop of care during the visit.
Pre-visit planning allows the team to complete all of the tasks for the visit (i.e., to “close the loop” of care) during the appointment, rather than having multiple follow-up items, such as laboratory results or medication adjustments, left unfinished at the close of the visit.
Take a long view: schedule several planned care appointments at once.
A visit planner can be used to set up more than one future appointment. For example, at this year's annual comprehensive care visit for a patient with diabetes, hypertension, and hypothyroidism, the physician may check off both a six-month follow-up (with A1c) as well as next year's annual visit (with diabetic panel, hypertension panel, TSH and mammogram). For those using open-access scheduling, the appropriate time intervals for appointments and associated labs can be tracked in a reminder system.
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.
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