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Preparation before office visits provides significant advantages for PCPs, patients
A recent study suggested a “primary care revolution” is coming that will increase the workload in the future for primary care physicians.
“Primary care teams will increasingly manage conditions that specialists managed in the past,” Andrew L. Ellner, MD, and Russell S. Phillips, MD, of the Center for Primary Care in Boston wrote in Journal of General Internal Medicine.
“Primary care will refocus on whole-person care, and address health behaviors as well as vision, hearing, dental, and social services,” they added.
To help put PCPs and other clinicians ahead of this predicted revolutionary curve, Healio Family Medicine interviewed American Academy of Family Physician members and other health care professionals about how clinicians can best prepare for patients and encourage patients to prepare for appointments in order to maximize office visits for both the clinician and the patient.
Use staff huddles
Huddles consist of several steps that are not complicated, according to Elizabeth Stewart, MD, and Barbara Johnson, MD. These consist of agreeing on a consistent time to meet; trying them out with different office members until you determine which staff members provide the most benefit, capping the huddle time to 7 minutes or less, conducting the huddle in a central location, and making everyone stand the entire time.
Huddles should be done before a patient arrives and can cover other important information, Ada Stewart, MD, of Eau Claire Cooperative Health Center in South Carolina and AAFP board member said.
These huddles have several benefits, added Ann Tseng, MD, of the department of family medicine at Oregon Health and Science University and Oregon Academy of Family Physicians member.
“What’s nice about huddles that include the support staff members is you can plan ahead, so the supporting staff members know how to assist you in tasks such as getting the appropriate paperwork and records. It really does help reduce some of the inefficiencies in the entire systemand thus helps reduce burnout as well,” she said.
“I hold a huddle with my staff prior to a patient’s arrival, making sure we are looking at each patient who is coming in for that particular visit, making sure that any referrals we actually did or were done on that's patient's behalf are being addressed and that we have that all ready,” she said.
Huddles may also provide benefits to patients and a practice’s bottom line. A 2012 paper found daily huddles at Cleveland Clinic within the institution’s lung transplant program resulted in a 1.5-day reduction in average length of patient stay, a 3% improvement in 30-day survival, a 6% reduction in total cost of care, and a 28% improvement in patient satisfaction with clinician communication.
Create a welcoming environment for patients
The Agency for Healthcare Research and Quality encourages health care professionals to assess their practice environment by conducting walk-throughs, including checking each sign in the office for visibility, readability, understandability. When appropriate, graphics and foreign languages should be considered.
Before he retired, John L. Pfenninger, MD, of the Medical Procedures Center in Midland, Michigan, wrote about the bistro, fireplace and television areas he created within his practice’s waiting room to help ensure an “inviting and comforting” environment. He also made sure reading materials were current and at least some of the chairs were user-friendly for the elderly.
“Simple comforts, but so appreciated,” he wrote in Family Practice Management, noting the waiting room and exam rooms have high windows that provide both light and privacy.
The welcoming environment may provide other another benefit, Pfenninger added.
“A respectful office likely reduces liability too. Think about those patients who have been waiting in a cramped area for 30 minutes. They are already upset when they see you, and if something goes wrong, they will quickly become angry,” he wrote. “On the other hand, if they are comfortable reading the newspaper and having a cup of coffee, even if they have to wait a while, they know that you are concerned and care about them. They come back to the exam room in a good mood, which paves the way for a successful visit.”
Ask patients to complete paperwork , assessments before the appointment
Having patients fill out comprehensive history forms, medication lists, and allergy listing ahead of time is perfectly acceptable, according to Lynn Rapsilber, DNP, APRN, ANP-BC, FAANP, a nurse practitioner and reimbursement specialist based in Connecticut.
The Agency for Healthcare Research and Quality’s website also states that everyone who needs to fill a form out should be offered assistance in doing so.
“You can't tell by looking which patients may need assistance, so offer all patients help with the forms that they are asked to fill out or sign,” the agency said. “Offer help in a friendly, non-stigmatizing way [by saying] ‘If anything on the form is not clear, let me know and I'll be happy to go over it with you.’ or ‘Thank you for filling out the form. Can we go over it to be sure we got everything? Some questions are not always clear and we want to be sure we have the correct information.’”
Other research has suggested routine laboratory tests be completed prior to the appointment so another appointment does not have to be made to discuss them.
Suggest patients keep medical journals
Patients should record health concerns as they experience them or keep a list of medications as they begin taking them so that time is not wasted waiting for the patient to recall these details, Ada Stewart said in an interview.
“Tell patients to keep an ongoing journal of aches, pains, what doctors they've seen, what pills they are taking and to bring it with them to the appointment,” she said.
“Some patients will also send themselves texts as reminders of what to tell their doctors and others take a picture of their medications with their smartphones to show me. That helps me see what's going on with them prior to their visits. So that's going to help save time,” she added.
Health systems may also want to consider asking patients to utilize electronic portals before their visit. These can ask general health questions such as date of last influenza vaccine or blood work or more specific queries, such as concerns regarding a certain medication the patient is taking, according to Jonathan S. Wald, MD, MPH, FACMI of Harvard Medical School, and colleagues. Their research that appeared in the Journal of the American Medical Informatics Association was one of the earliest studies that involving the use of electronic patient portals before a patient appointment.
Of 3,979 patients queried after using an electronic portal, 58% agreed or strongly agreed that their provider had more accurate information about them, 55.9% felt more prepared for their visit, 37.7% felt more satisfied with the visit, 37.2% felt communication with their provider during the visit improved, and 24.5% felt quality of care improved.
Of the 49 physicians surveyed, most recommended the e-portal to other clinicians and expressed overall satisfaction with them (P for trend = 0.0143) and 90% of physicians agreed or strongly agreed they wanted their patients to continue using the portal for medications/allergies, as well as 86% for diabetes care, 83% for health maintenance and 75% for family history.
The portal’s positive track record among both patients and doctors appears to have not diminished significantly in the decade-plus since Wald et al published their findings.
In addition, a 2017 review looked at the evidence on disparities in portal use, as well as the potential for using them for disease management, disease-specific portals, and disease prevention.
“Although findings have not been uniformly positive, several studies of the effectiveness of health care system patient portals in chronic disease management have shown promising results with regard to patient outcomes. Patient web portals have also shown promising results in increasing adherence with screening recommendations,” Steven S. Coughlin, PhD, MPH, of the department of clinical and digital health sciences at Augusta University in Georgia, and colleagues wrote in Risk Management and Healthcare Policy.
Tomorrow, Healio Family Medicine will review tips from clinicians and other sources on how to maximize face time with patients, and then on Wednesday, provide recommendations from experts on how clinicians can better ensure proper reimbursement after the conclusion of an office visit. – by Janel Miller
References:
Agency for Healthcare Quality. Health literacy universal precautions toolkit, 2nd Edition. Welcome patients: Tool #13. https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool13.html. Accessed Sept. 7, 2018.
Cosgrove D, et al. “A CEO checklist for high-value health care.”
Coughlin SS, et al. Risk Manag Healthc Policy. 2017;doi:10.2147/RMHP.S130431
Ellner AL and Phillips RS. J Gen Intern Med. 2017;doi:10.1007/s11606-016-3944-3/
Stewart EE and Johnson BC. Fam Pract Manag. 2007; Jun;14(6):27-9.
Wald JS, et al. J Am Med Inform Assoc. 2010;doi:10.1136/jamia.2009.001362.
Disclosures: Healio Family Medicine was unable to determine relevant financial disclosures prior to publication.