1. Process Redesign Connie Sixta, RN, PhD, MBA Patricia L. Bricker, MBA

2. Reasons for Visit Redesign Assure information needed for the visit is available Decrease wasted time during the visit Increase the value of the visit by addressing all needs Prevent re-work related to non-completed labs/tests Increase visit efficiency by staging completion of tasks Increase provider capacity by making sure the provider does provider tasks Increase team capacity through maximization of skills and use of standing orders Increase care effectiveness by addressing priority needs Increase overall visit throughout by increased planning and organization

3. Redesign the Pre-visit, Visit, and Post-visit Processes Pre-visit MA completion of clinical guidelines per standing orders (i.e. A1c, LDL, microalbuminuria, eye exam) prior to the visit Visit MA/RN review of current meds, completion of screenings, immunizations, self-management goal setting per standing orders prior to physician-patient interaction Provider management of clinical outcomes, risk, etc. Post-visit Follow-up of new prescriptions, response to meds, completion of referrals

4. Sample pre-visit, visit, and post-visit processes

5. MA faxes request for retinal exam report to ophthalmologist MA reviews eye exam report, A1c, LDL, and microalbuminuria reports and creates patient report card MA identifies guidelines per patient that need to be completed per standing orders & highlights them Sample: Pre-visit Process MA calls & reminds patient of visit; confirms eye exam completion; asks patient to get A1c, LDL and microalbuminuria completed & bring meds to office 1-2 weeks ahead, MA identifies DM patient scheduled for appointments

6. KeyKey ProcessProcess Beginning Beginning KeyKey ProcessProcess Beginning Beginning KeyKey ProcessProcess Beginning Beginning KeyKey ProcessProcess Beginning Beginning KeyKey ProcessProcess Beginning Beginning Sample Visit Process Patient (Pt) checks in at front desk. Pt given depression screening & self-management (SM) tool to complete Front desk notifies MA of Pt arrival MA takes Pt back to room, completes/documents Ht, Wt, BP, BG, history, depression screening & reviews Pt meds versus EMR, report card & assists Pt in setting SM goal MA enters data into the risk assessment tool MD reviews lab, risk status, and current meds with Pt.; orders new BP & A1c meds; discusses new treatment plan and reinforces Pt SM goal MA asks Pt to recap conversation with MD, share SM goal, self- care needs/schedule (closing the loop) MA and Pt agree on date, time, and purpose of follow-up phone call. MA huddles with MD to discuss labs, Pt concerns, problems, risk, report card Pt has no questions so MA takes Pt to checkout

7. KeyKey ProcessProcess Beginning Beginning KeyKey ProcessProcess Beginning Beginning KeyKey ProcessProcess Beginning Beginning KeyKey ProcessProcess Beginning Beginning KeyKey ProcessProcess Beginning Beginning Sample Post-Visit Process MA reviews daily call schedule and calls Pt at agreed upon time MA introduces self to Pt and asks how the Pt is doing since the visit Pt describes how she is feeling, shares concerns, BP log, response to meds and success with SM goal MA documents concerns and response to meds and success with SM goal. Tells Pt next step is review with MD MA calls Pt back and relays discussion with MD that Pt needs to continue new medication MA reviews BP log, & response to new med with MD; MD decision to continue med MA schedules follow-up call with Pt and closes the loop

8. Major Changes Patient totally prepared for visit with lab and referral reports completed so that clinical outcomes can be addressed Prior to MD-patient interaction, standing orders completed, data collected, screenings done, and SM goal set MD-patient interaction focuses on patient risk, interventions needed, plan of care and reinforcement of SM goal Visit pre-planned and organized to give patient highest value

9. What Does Your Process Look Like?