Table of Contents s311

Conducting a Continuing Care Clinic

Handbook for Practice Teams

March 5, 2001 Center for Health Studies Group Health Cooperative

G:\INST\RWJ-NPO\Toolkits\0d7693de6246d3983200dc8a41f412ee.doc 04/27/18 2

Table of Contents

Overview 2 FastFacts 3 Designing a CCC 4 Clinical Roles 6 Team Meetings 7 Scheduling Checklist Template 8 Clinical Priorities for Diabetes and the Frail Elderly 9 Timeline 10 Scheduling Templates: AM clinic, one MD 11 AM clinic, two MDs 12 PM clinic, one MD 13 Sample letter to patient 14 Older Adult Worksheet 15 Geriatrics 101 16

This guide is intended to assist practice teams in using the continuing care clinic model for managing patients with a selected diagnosis or condition, such as diabetes or frail elderly. The guide is considered a template which can be modified to fit the needs of individual teams.

THE CONTINUING CARE CLINIC VISIT and YOUR PRACTICE

A Tool for Implementing Population-based Managed Care for Your Patients with Selected Medical Conditions

A Primary Care Tool to Assist with the Care of Patients with Chronic Conditions:

One method for caring for patients with chronic conditions is a regularly scheduled "Continuing Care Clinic." The Clinic brings groups of patients to the primary care facility at one time. Patients receive the necessary routine primary care through one-on-one time with their physician and other team members and education in a group setting. In essence, the clinic visit allows patients to experience one-stop chronic illness care during a half-day visit. As an option, the primary care physician may want to consider having joint visits with the appropriate specialty care physician.

Elements of Care Incorporated in the Continuing Care Clinic:

1. Routine clinical/preventive care: for example, for patients with diabetes; eye and foot care, psycho-social assessment, specialty referrals, nutrition counseling, labs and lifestyle assessments 2. Drug management: simplicity, avoidance of adverse effects, cost, adherence. 3. Periodic health status assessments. 4. Patient education and coaching integrated into care. 5. Support and assistance with behavioral and life style changes. 6. Contact with primary care team enhanced.

Key Objectives for the Continuing Care Clinic:

1. Prevent or minimize complications for patients which may lead to excess disability. 2. Proactively manage the care of a specific populations, especially coordination of preventive services, through the use of priority worksheets and/or computerized patient registry and information system (such as is currently available for heart care and diabetes). 3. Systematic inclusion of all patients in a population to ensure that necessary routine care is accomplished on an automatic basis in a supportive group environment. 4. Tests and evaluations are done based on evidence of efficacy (when available) or on established standards of care. 5. The care delivery team actively defines roles to deliver the needed components of care. 6. Patients and physicians remain partners in determining the plan of care. 7. Outcome-based evaluation processes are built into system.

Key Outcomes Achieved via Regularly Scheduled Continuing Care Clinics:

1. Overall patient health status (for example, reduce glycosolated hemoglobins, foot ulcers, blood pressure, functional status). 2. Consumer satisfaction with health care delivery (regularly scheduled one stop care). 3. Provider satisfaction with chronic illness care and patient tracking. 4. Reduction in unnecessary utilization (ER visits, Hospitalizations, Urgent Care Visits).

Continuing Care Clinic Fast Facts for Provider Teams

What work is required?

 Review your patient panel to determine focus of continuing care clinic and to exclude those who are inappropriate for the visit.

How many patients do I need to “see”?

 Each half day Continuing Care Clinic has appointment slots for 8 or more patients (a cohort.) There is a one hour block (while the patients are in the group meeting) when the physician may perform other duties. The nurse may be involved in the group meeting.

How are patients chosen?

 Patients are selected from among those in your panel: Each practice may determine the focus of the continuing care clinic Some examples include: diabetes, cardiac disease, frail elderly, multiple sclerosis.

 The clinic is described to patients, who may choose not to participate.

What else will I need to do?

 Each team will need to meet regularly for planning care to the continuing care clinic group.

Suggested Protocols for Designing A Continuing Care Clinic to Fit Your Practice

A Planning Guide

Patient Scheduling Considerations:

1. Review your patient panel and determine the focus of the continuing care clinic.

2. Determine the Continuing Care clinic (CCC) schedule needed to see all your patients at a predetermined interval during the year. You will need to know:

# of patients with the condition of interest # of CCC visits each ear # of patients per CCC cohort (typically 12, allowing for some absences at each visit)

a) Divide the # of patients by the # in the cohort Ex: 120 patients with diabetes = 10 cohorts 12

b) Determine the visit interval and assign cohorts to a schedule Ex: Every 3 months Jan – May – Sept = 2 cohorts (1 starting in Jan, 1 in May) Feb – June – Oct = 3 cohorts (1 starting each month) Mar – July – Nov = 3 cohorts (1 starting each month) April – Aug – Dec = 2 cohorts (1 starting in Apr, 1 in Aug)

c) Thirty ½-days will be needed: Jan: 2 ½-days Feb: 3 ½-days Mar: 3 Apr: 2 May: 2 June: 3 July: 3 Aug: 2 Sep: 2 Oct: 3 Nov: 3 Dec: 2

3. Once the CCC schedule is determined, schedule the half-days for the next year. Be sure to block off actual time slots for MD on visit day in your appointment system. Schedule, RN, pharmacist or other team members. Assign cohorts of approximately 12 patients to each schedule.

4. At routine intervals about 1 month before their first scheduled CCC, mail a letter of introduction about the CCC to the selected patients to determine their interest in participation.

5. Two weeks after sending the letter, and prior to the first CCC visit, call patients and confirm their attendance.

6. Review patients' medical records and determine clinical priorities.

7. Using the scheduling template provided, lay out each patient schedule of care for the visit: Be sure the patient is not in two places at once or that the same provider is seeing two patients at once!

8. Complete individual patient schedules and mail to patient along with confirmation letter (sample provided); be sure patient receives confirmation of CCC visit two weeks ahead of the visit day so that they can visit the lab to have requested blood work done as needed.

9. Order lab work and send lab requisitions to appropriate lab facility as needed.

10. Call patients 1 week prior to visit day to remind about schedules and lab work.

Clinical Facility Preparation Considerations:

1. Arrange telephone and visit coverage and plan for RN seeing patients during CCC visits.

2. Arrange for Medical Assistant during the CCC.

3. Schedule room large enough to handle all patients during patient education class.

4. If appropriate, arrange with registration personnel to have patients register once for all care services they are to receiving so patient is only charged one copay for all scheduled visits.

5. Arrange for three exam rooms so patients can be visiting with pharmacist, RN, and MD at same time.

Continuing Care Clinics Clinical Roles

Clinical Roles: (revised according to team configuration)

Clinic Coordinator: Assist with communications at facility (clinical staff, business office) Reserve rooms as needed Assist with identification of dates for team meetings and clinics

Office assistant: Identify tentative dates for clinic with all staff involved Hold appts in schedule when clinic dates are determined. Assure that appointments for individuals attending the clinic are entered into appointment system. Schedule clinics with patients Reserve conference room Send notification to patients Distribute schedules to team members Call patients to remind of clinic 1-2 days before scheduled clinic

MA or LPN: Greet and escort/direct patients. Be responsible for managing patient flow. Collect and record vital signs and other assessments as needed Assist with group visit logistics.

RN: Pre Clinic: Review charts and notify assistant of any labs needed Establish group focus (with social worker if available) Participate in arranging for guest speakers when content requires. At Clinic: Meet with patients one-on-one focusing on self care behavior changes Lead group (in some settings) Btwn clinics: Identify common information needs of patients for inclusion in group. Telephone follow-up with patients for behavior change support.

MD:. At Clinic: Formulate, communicate and oversee plan of care for patients.

MSW: Pre clinic: Meet with RN to plan for group sessions. At Clinic Actively facilitate group session, individual visits as needed.

Pharmacist At Clinic: Review all patients medications with the patient at least annually. or ID drug related problems and recommend medication changes to MD. other specialist Participate in group sessions when content is relevant. involvement: Track medication related intervention outcomes, costs and savings.

Continuing Care Clinics

Each team is encouraged to hold routine meetings. The following topics may be useful.

First Team Meeting

I (2 min) Review/Modify Agenda Goal: Identify all issues to be covered at meeting

II (35 min) Planning for the Continuing Care Clinics Goals: 1) Review purposes/goals of clinic 2) Make necessary decisions to implement first clinic A. Review purposes of clinics and goals for first clinic, including schedule of clinical priorities to be addressed during the year (5 min) B. Determine number of cohorts. (Review lists of participants) C. Verify dates and hours of first clinics; (Are all team members (MSW, RN, MD available ?) (Choose appointment schedule - appt lengths) D. Identify patients for clinics. E. Determine if/when lab work needed (glycoHb, lipids, BUN, creat.) G. Identify practice contact person H. Verify date for next team meeting

III (3 min) Meeting evaluation Goal: Determine what worked, what didn’t for future meetings

Second Team Meeting:

“Walk through” of first clinic - paperwork, team communication, group session and follow-up planning.

Scheduling Checklist Template

Steps Clinic Coord Off. Asst. RN SW I.D. tent. dates for clinic X Hold on appt. book X Holds on other schedules X OK date with: MD X RN X Pharm X MSW if avail X Nutrition prn X Reserve group room X Call Patients X Identify lab for each pt, X notify pt. Fill out lab slips and X provide to Office Asst. Draft Schedule X Confirm coverage X Establish group focus X X Final schedule to: X team (3 copies), Clin Coord, pharmacy, (MSW, nutrition) Mail pt letter X Phone patients to remind X Chart Review before X clinic (RN/MD) Debrief following clinic X X X X

Continuing Care Clinics Sample Clinical Priorities For Diabetes and Frail Elderly Clinical priorities should be derived from evidence-based guidelines which include treatment protocols.

Diabetes: 1) Reduction of macrovascular complications (smoking cessation, BP control, daily ASA, Lipids) 2) Reduction of microvascular complications (foot, kidney, eyes) 3) Function/Affect (functional status, depression and incontinence) 4) Self Management (diet, exercise, etc.) 5) Glucose control

Routine Assessments: self management behaviors feet glycohemoglobin lipids microalbuminuria

Elderly: 1) Medication management (four or fewer meds; avoid sedatives) 2) Reduce risk of falls (mobility/fitness/exercise, alcohol use, home safety) 3) Function/Affect (physical function, depression and incontinence) 4) Chronic Illness Management 5) Planning for the Future (Durable POA, Advance Directive)

Routine Assessments: functional status depression incontinence self management behaviors medications falls

Sample Schedule

First Clinic Visit (baseline)

Clinic: Pharmacy Brown Bag, Review status, identify priorities for change Develop and document a plan for care Group: Introduction to clinic and one another; activation, identify issues for future sessions

Interim telephone follow up: behavior change support and clinical status

Second Clinic Visit (3-4 months)

Clinic: Follow Up on Plans Foot Assessments for diabetics; Nutrition visits for selected patients Pharmacy follow up on selected patients Group: Cardiovascular risk reduction (Exercise) or Nutrition, or topic chosen by group on first visit

Third Clinic Visit (8-9 months)

Clinic: review health maintenance needs, reevaluate self management, follow-up Group: Varies depending on cohort needs and desires (Nutrition, Exercise, Home Safety, Depression, Fatigue, Adv. Directives, Community Resources)

Fourth Clinic Visit (12 months)

Clinic: Annual assessments and self care/educational needs Group: Varies

Sample Patient Letter Dear ______, In order to better care for patients with X (condition,) we are beginning a Continuing Care Clinic (CCC.) Patients who participate in the CCC will be scheduled to come to the clinic (three) times each year. At each visit, you will see the pharmacist, doctor, and nurse, and have an opportunity to participate in an educational and supportive group. These planned visits will allow us to concentrate on the care of X. You are invited to the first CCC (next month.) ______, RN will be calling you in the next few weeks to describe the CCC in more detail and schedule your visit. You may contact (him/her) at (phone #) if you prefer. Your participation is voluntary, but we are confident that you will benefit from the CCC. We look forward to talking with you about the CCC. Sincerely, ______, MD for the health care team at ______Clinic

Continuing Care Clinic “Working together to maintain your health”

______

Your CCC visit is scheduled for*:______

Please check-in at: ______Group session:______

Pharmacist visit: ______

MD visit: ______

RN visit: ______

Other:______Your spouse or other family member or friend is welcome to attend the clinic with you. We look forward to seeing you.

If you find a lab slip enclosed, please have lab work done during the week prior to your clinic appointment. This will ensure that results are available for review during your visit.

THIS IS AN APPOINTMENT. PLEASE CALL AND LET US KNOW IF YOU WILL NOT BE ABLE TO ATTEND

(CLINIC) - APPOINTMENT #: (***)

One Provider, Morning Clinic, 15 minute visits

Check In Pharmacy MD RN Group Patient #1 8:40 8:45-9:00 9:00-9:15 9:15-9:30 10:30-11:15

Patient #2 8:55 9:00-9:15 9:15-9:30 9:30-9:45 10:30-11:15

Patient #3 9:10 9:15-9:30 9:30-9:45 9:45-10:00 10:30-11:15

Patient #4 9:25 9:30-9:45 9:45-10:00 10:00-10:15 10:30-11:15

Patient #5 9:40 9:45-10:00 10:00-10:15 11:30-11:45 10:30-11:15

Patient #6 9:55 10:00-10:15 11:30-11:45 11:45-12:00 10:30-11:15

Patient #7 9:55 10:15-10:30 11:45-12:00 12:00-12:15 10:30-11:15

Patient #8 10:25 11:30(or no visit) 12:00-12:15 12:15-12:30 10:30-11:15

G:\INST\RWJ-NPO\Toolkits\0d7693de6246d3983200dc8a41f412ee.doc 04/27/18 Continuing Care Clinics Schedule Template - Dual (two concurrent) AM clinics MD A Name Check in Pharmacy MD Visit RN Visit Group Session Patient #1 8:40 8:45-9:00 9:00-9:15 9:15-9:30 10:30-11:15 Patient #2 8:55 9:00-9:15 9:15-9:30 9:30-9:45 10:30-11:15 Patient #3 9:10 9:15-9:30 9:30-9:45 9:45-10:00 10:30-11:15 Patient #4 9:25 9:30-9:45 9:45-10:00 10:00-10:15 10:30-11:15 Patient #5 9:40 9:45-10:00 10:00-10:15 11:30-11:45 10:30-11:15 Patient #6 10:25 no pharmacy 11:30-11:45 11:45-12:00 10:30-11:15 Patient #7 10:25 no pharmacy 11:45-12:00 12:00-12:15 10:30-11:15 MD B Name Check in Pharmacy MD Visit RN Visit Group Session Patient #1 9:25 no pharmacy 9:30-9:45 9:45-10:00 10:30-11:15 Patient #2 9:40 no pharmacy 9:45-10:00 10:00-10:15 10:30-11:15 Patient #3 10:05 10:10-10:25 11:30-11:45 11:45-12:00 10:30-11:15 Patient #4 10:25 11:30-11:45 11:45-12:00 12:00-12:15 10:30-11:15 Patient #5 10:25 11:45-12:00 12:00-12:15 12:15-12:30 10:30-11:15 Patient #6 10:25 12:00-12:15 12:15-12:30 12:30-12:45 10:30-11:15 Patient #7 10:25 12:15-12:30 12:30-12:45 12:45-1:00 10:30-11:15

t:inst/rwj/ccc/handbook/sched2am.doc Chronic Care Clinics Schedule Template - PM clinic

Name Check in Pharmacy MD Visit RN Visit Group Session Patient #1 1:25 1:30-1:45 1:45-2:00 2:00-2:15 3:30-4:15 Patient #2 1:40 1:45-2:00 2:00-2:15 2:15-2:30 3:30-4:15 Patient #3 1:55 2:00-2:15 2:15-2:30 2:30-2:45 3:30-4:15 Patient #4 2:10 2:15-2:30 2:30-2:45 2:45-3:00 3:30-4:15 Patient #5 2:25 2:30-2:45 2:45-3:00 3:00-3:15 3:30-4:15 Patient #6 2:40 2:45-3:00 3:00-3:15 4:30-4:45 3:30-4:15 Patient #7 2:55 3:00-3:15 4:30-4:45 4:45-5:00 3:30-4:15

t:inst/rwj/handbook/schedpm.doc 4/27/2018