1. System Changes and Interventions: Planned Care
Mike Hindmarsh
Improving Chronic Illness Care,
a national program of the Robert Wood Johnson Foundation
IDCOP National Summit
Chicago
May 13-15, 2002

2. Delivery System Design
Define roles and delegate tasks amongst team members.
Use planned visits to support evidence-based care.
Build effective case management skills into practice
Assure continuity by the primary care team.
Assure regular follow-up.

3. Roles in Team Care

4. Group Visits: A Primer
Patients brought in by clinically relevant groups
Patients can receive:
Specialty service as needed/available
One-on-one with medical provider
Medication counseling
Self-management support training
Social support
Multiple Models for Group Visits

5. What is a Planned Visit?
A Planned Visit is an encounter with the patient initiated by the practice to focus on aspects of care that typically are not delivered during an acute care visit.
The provider’s objective is to deliver evidence-based clinical management and patient self-management support at regularly scheduled intervals without the “noise” inherent in the acute care visit.

6. What does a Planned Visit look like?
The provider team proactively calls in patients for a longer visit (20-40 minutes) to systematically review care priorities.
Visits occur at regular intervals as determined by provider and patient.
Team members have clear roles and tasks.
Delivery of clinical management and patient self-management support are the key aspects of care.

7. How do you do a Planned Visit?
You Plan It!

8. Step One: Example Senior Care Polypharmacy
Choose a patient sub-population, e.g., all patients >75 on five or more medications
Have programming support person or pharmacy generate list of patients and medications
MD reviews list for patients at highest risk (see handouts)

9. Step Two: Patient Outreach
RN/LPN/MA checks to see if patient is on any registries
Have PCR call patient and explain the need for planned visit
Allow patient to choose day and time for visit
Ask patient to bring in bag of all medications they are taking (including OTCs and herbals)

10. Step Three: Preparing for the Visit
RN/LPN/MA prints any relevant patient summaries from registries and attaches to front of chart
MD reviews medications prior to visit, and consults with pharmacy as needed

11. Step Four: The Visit Review patient’s medication regimen
Identify and eliminate unnecessary drugs
Adjust remaining medications as needed
Problem solve adherence issues with patient
Create an patient action plan
Schedule follow-up

12. Follow-up Does not need to be in-person visit (use phone, email)
Check adherence to action plan
Problem solve as needed
Schedule additional follow-up as needed