The start of each day buzzes at Patient Centered Medical Homes (PCMHs) as the medical team “huddles up” to prepare for the day’s scheduled patients.
There’s a lot of information to consider. Patients with a wide range of divergent medical needs will walk through the doors, propelling physicians, nurses and other clinical staff into full care mode. The choreography gets complex. Which patients need which tests? Has a particular patient scheduled to arrive actually received a test that had been ordered? Are those results in the center’s system and ready to be handed off to the physician who will treat the patient?
With all this information often scattered across multiple reports, wouldn’t it be easier if all the information were consolidated into one comprehensive report that the entire staff could use?
Well, there is.
Heather Budd, VP of Clinical Transformation at Azara Healthcare and a growing number of PCMHs are embracing the Visit Planning Report concept, which organizes each day of scheduled patient visits into one streamlined report. So, when the care team gets in the morning huddle, each refers to one report.
“The intent of this report is to do proactive visit planning,” said Budd. “It’s in accordance with the philosophy of the Patient Centered Medical Home, which is to try to delegate some of the provider to the support staff.”
Azara has developed the Visit Planning Report as part of its DRVS (pronounced Drives) data analytics and reporting tool.
The report began to evolve when Budd worked for a health center. She and other team members tried to achieve visit planning by using registry reports, which are a list of patients and metrics arranged by chronic illness. The process proved to be too cumbersome to work effectively.
“If you’re try to prepare for patients coming in the next day, you might have to run six or seven of those reports with all the chronic illnesses that you’re following, plus preventative care to get the whole list and figure out what needs to be done for each patient,” said Budd. “That’s obviously not very efficient.”
The Visit Planning Report streamlines the process by pulling all illnesses and diagnoses into one repot that is actionable and clear to the support staff.
Azara arranged the report’s layout in conjunction with a health center client that referred to it as the “no missed opportunities report” because it aims to ensure that the onsite treatment process is as complete as possible, negating the need to call the patient afterwards because something was missed.
The reports are typically run the evening before or the morning of the appointments. The data is organized chronologically, with the day’s schedule of patients running down one side of the report. Each patient entry includes basic information, such as age, gender and the preferred language the patient prefers to receive their care.
Other information includes disease diagnoses, such as diabetes and hypertension, and risk factors, such as tobacco use and pregnancy. Budd said Azara is beginning to bring in severe mental illness and substance abuse as risk factors because they impact the way the care team chooses to deliver care to the patient.
Another key component of the report is the “alert type” which informs the care team about tests that are missing, overdue or produced results that are out of range, which indicate a patient may need to take specific actions to improve his or her health.
“The idea is that the team can work with standing orders in the policies and procedures of the clinic to execute these orders on behalf of the provider, so when the provider walks in the room to see the patient he or she has the most up to date information and can make the best decisions for the patient’s care.”