[Skip to Content]
[Skip to Content Landing]

Pre-Visit PlanningSave Time and Improve Care

Learning Objectives:
At the end of this activity, you will be able to:
1. Identify the purpose and benefits of implementing pre-visit planning;
2. Describe steps to take during a visit to improve patient experience;
3. Recognize ways to prepare and engage patients in their health care;
4. List pre-visit planning tools and strategies that improve practice efficiency.
0.5 Credit CME
How will this module help me successfully adopt pre-visit planning?

  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.

Introduction

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.

Ten steps to implement pre-visit planning:
During the current visit

  • 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.

Look back

  • 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.

Plan forward

  • 8. Hold a pre-clinic team huddle.

  • 9. Use a pre-appointment questionnaire.

  • 10. Hand off patients to the physicians.

Interactive Calculator: Pre-visit planning

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.

Interactive
Time and cost savings calculator
Time and cost savings calculator
Ten steps to implement pre-visit planning

A reference for implementing the 10 steps of pre-visit planning

During the current visit
Step 1Re-appoint the patient at the conclusion of the visit.

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

Amy Haupert, MD, Family Medicine, Allina Medical Clinic, Cambridge, MN

Box Section Ref ID

Q&A

Step 2 Use a visit planner checklist to arrange the patient's next appointment(s).

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.

Box Section Ref ID

Q&A

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

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.

Box Section Ref ID

Q&A

“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

J. Benjamin Crocker, MD, Internal Medicine, Ambulatory Practice of the Future, Boston, MA

Look Back
Step 4 Perform visit preparations.

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.

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

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.

Step 6 Send patients appointment reminders.

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.

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

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
Plan Forward
Step 8 Hold a pre-clinic care team huddle.

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.

Step 9 Use a pre-appointment questionnaire.

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.

Box Section Ref ID

Q&A

Step 10 Hand off patients to the physician.

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.”

Box Section Ref ID

Q&A

Conclusion

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.

Box Section Ref ID

AMA Pearls

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.

Glossary

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.

Sign in to take quiz and track your certificates

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

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 0.5 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

Successful completion of this CME activity, which includes participation in the activity and individual assessment of and feedback to the learner, enables the learner to earn up to 0.5 MOC points in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABP MOC credit.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn their required annual part II self-assessment credit in the American Board of Otolaryngology – Head and Neck Surgery’s Continuing Certification program (formerly known as MOC). It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of recognizing participation.

Successful completion of this CME activity, which includes participation in the activity and individual assessment of and feedback to the learner, enables the learner to earn up to 0.5 MOC points in Lifelong Learning (Part II) of the American Board of Pathology’s (ABPath) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABPath MOC credit.

Article Information

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this enduring material activity for a maximum of .50 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Target Audience: This activity is designed to meet the educational needs of practicing physicians, practice administrators, and allied health professionals.

*Disclaimer: Individuals below who are marked with an asterisk contributed towards Version 1 of this learning activity.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice, interdisciplinary teamwork, quality improvement and informatics.

Planning Committee:

  • Christine A. Sinsky, MD, FACP, Vice President, Professional Satisfaction, American Medical Association*

  • Marie Brown, MD, Senior Physician Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association & Associate Professor, Rush Medical College, Rush University Medical Center

  • Ashley C. Cummings, MBA, CRCR, CME Program Committee, American Medical Association

  • Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Kevin Heffernan, MA, CME Program Committee, American Medical Association*

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Rhoby Tio, MPPA, Senior Policy Analyst, Professional Satisfaction and Practice Sustainability, American Medical Association*

Content Reviewers:

  • J. James Rohack, MD, FACC, FACP, Senior Advisor and former President, American Medical Association

  • Renee DuBois, MPH, Senior Practice Transformation Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association

  • Brittany Thele, MS, Program Administrator, Professional Satisfaction and Practice Sustainability, American Medical Association

  • John W. Beasley, MD, Family Physician, School of Medicine and Public Health, University of Wisconsin–Madison*

  • David Eltrheim, MD, Family Physician, Mayo Clinic Health System–Red Cedar*

  • Catherine Sonquist Forest, MD, MPH, Clinic Chief, Stanford Family Medicine*

  • Chester H. Fox, MD, Professor of Family Medicine, University at Buffalo*

  • Ethan A. Halm, MD, MPH, Chief, Division of General Internal Medicine, University of Texas Southwestern Medical Center*

  • Jeffrey Panzer, MD, Medical Director, Oak Street Health*

  • Rachel Willard-Grace, MPH, Research Manager, Center for Excellence in Primary Care, Department of Family & Community Medicine, University of California–San Francisco*

  • Michael Zimmerman, MD, Co-founder, Temescal Creek Medicine*

  • Michael Glasstetter, Vice President, Advocacy Operations, Advocacy Planning & Management, American Medical Association*

  • Thomas P. Healy, JD, Vice President and Deputy General Counsel, American Medical Association*

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, American Medical Association*

  • Rhoby Tio, MPPA, Senior Policy Analyst, Professional Satisfaction and Practice Sustainability, American Medical Association*

About the AMA Professional Satisfaction and Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

The project described was supported by Funding Opportunity Number CMS-1L1-15-002 from the U.S. Department of Health & Human Services, Centers for Medicare & Medicaid Services. The contents provided are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.

ABMS MOC: Through the American Board of Medical Specialties (“ABMS”) ongoing commitment to increase access to practice relevant Maintenance of Certification (“MOC”) Activities, this activity has met the requirements as an MOC Part II CME Activity. Please review the ABMS Continuing Certification Directory to see what ABMS Member Boards have accepted this activity.

Renewal Date: February 2, 2018; April 25, 2019

References
1.
Agency for Healthcare Research and Quality. (2017).  Warm handoff: Intervention.  Retrieved from www.ahrq.gov/professionals/quality-patient-safety/patient-family-engagement/pfeprimarycare/interventions/warmhandoff.html
2.
AACE/ACE Consensus Statement. (2018).  Consensus Statement by the American Association of Clinical Endocrinology on the comprehensive type 2 diabetes management algorithm.  Endocrine Practice, 24(1). doi: 10.4158/CS-2017-0153Google Scholar
3.
ATA/AACA Guidelines. (2012).  Clinical practice guidelines for hypothyroidism in adults: Cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association.  Endocrine Practice, 18(6). Retrieved from www.aace.com/files/final-file-hypo-guidelines.pdfGoogle Scholar
4.
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA. (2018).  Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.  Journal of the American College of Cardiology, 71(19), e127–e248; doi: 10.1016/j.jacc.2017.11.006Google ScholarCrossref
5.
U.S. Preventive Services Task Force. (2018).  Final Update Summary: Breast Cancer: Screening.  Retrieved from www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1
6.
Baron,  R. (2010).  What's keeping us so busy in primary care? A snapshot from one practice.  New England Journal of Medicine, 363, 495–496. doi: 10.1056/NEJMon0910793Google ScholarCrossref
7.
Casalino,  L., Nicholson,  S., Gans,  DN.,  et al. (2009).  What does it cost physician practices to interact with health insurance plans?  Health Affairs, 28(4), 533–543. doi: 10.1377/hlthaff.28.4.w533Google ScholarCrossref
8.
Day,  J., Scammon,  DL., Kim,  J.,  et al. (2013).  Quality, satisfaction and financial efficiency associated with elements of primary care practice transformation: preliminary findings.  Annals of Family Medicine, 11(1), S50–S59. doi: 10.1370/afm.1475Google Scholar
9.
Farber,  J., Siu,  A., Bloom,  P. (2007).  How much time do physicians spend providing care outside of office visits?  Annals of Internal Medicine, 147(10), 693–698. doi: 10.7326/0003-4819-147-10-200711200-00005Google ScholarCrossref
10.
Gottschalk,  A., Flocke,  SA. (2005).  Time spent in face-to-face patient care and work outside the examination room.  Annals of Family Medicine, 3(6), 488–493. doi: 10.1370/afm.404Google ScholarCrossref
11.
Hunt,  VL., Chaudhry,  R., Stroebel,  RJ., North,  F. (2011)  Does pre-ordering tests enhance the value of the periodic examination? Study design – Process implementation with retrospective chart review.  BMC Health Services Research, 11, 216. doi: 10.1186/1472-6963-11-216Google ScholarCrossref
12.
Kabcenell,  AI., Langley,  J., Hupke,  C. (2006).  Innovations in Planned Care.  IHI Innovations Series white paper. Retrieved from http://www.ihi.org/knowledge/Pages/IHIWhitePapers/InnovationsinPlannedCareWhitePaper.aspxGoogle Scholar
13.
McAllister,  JW., Cooley,  WC., Van Cleave,  J., Boudreau,  AA., Kuhlthau,  K. (2013).  Medical home transformation in pediatric primary care–what drives change?  Annals of Family Medicine, 11 (1), S90–S98. doi: 10.1370/afm.1528Google ScholarCrossref
14.
Montori,  VM., Dinneen,  SF., Gorman,  CA.,  et al; and Translation Project Investigator Group. (2002).  The impact of planned care and a diabetes electronic management system on community-based diabetes care: the Mayo Health System Diabetes Translation Project.  Diabetes Care, 25(11), 1952–1957. doi: 10.2337/diacare.25.11.1952Google ScholarCrossref
15.
Moore,  LG. (2006).  Escaping the tyranny of the urgent by delivering planned care.  Family Practice Management, 13 (5), 37–40. Retrieved from http://www.aafp.org/fpm/2006/0500/p37.htmlGoogle Scholar
16.
Sinsky,  CA., Willard-Grace,  R., Schuztbank,  AM., Sinsky,  TA., Margolius,  D., Bodenheimer,  T. (2013).  In search of joy in practice: a report of 23 high-functioning primary care practices.  Annals of Family Medicine, 11 (3), 272–278. doi: 10.1370/afm.1531Google ScholarCrossref
17.
Stone,  EG., Morton,  SC., Hulscher,  ME.,  et al. (2002).  Interventions that increase use of adult immunization and cancer screening services: a meta-analysis.  Annals of Internal Medicine, 136 (9), 641–651. doi: 10.7326/0003-4819-136-9-200205070-00006Google ScholarCrossref
18.
Crocker,  B., Lewandrowski,  EL., Lewandrowski,  N., Gregory,  K., Lewandrowski,  K. (2013).  Patient satisfaction with point-of-care laboratory testing: report of a quality improvement program in an ambulatory practice of an academic medical center.  Clinica Chimica Acta, 424, 8–11. doi: 10.1016/j.cca.2013.04.025Google ScholarCrossref
19.
Crocker,  JB., Lewandrowski,  E., Lewandrowski,  N., Baron,  J., Gregory,  K., Lewandrowski,  K. (2014).  Implementation of point-of-care testing in an ambulatory practice of an academic medical center.  American Journal of clinical Pathology, 142(5), 640–646Google ScholarCrossref

Name Your Search

Save Search

Lookup An Activity

or

My Saved Searches

You currently have no searches saved.

Topics
State Requirements