We have been piloting group visits and creating new Shared Care Plans for our patients 65 and older with complex medical problems.
We have been updating existing Shared Care Plans in office visits.
We have assessed the amount of time needed for data entry of the Shared Care Plan to review all 7 tabs ~ adding new Care Team members, editing medications, adding new medications, and determining Goals and Next Steps.
In the new world, this would be an ideal scenario:
1. Do a mailing to the patient with a blank paper version of the electronic Shared Care Plan and include instructions from our patient guide.
2. Instruct the patient to fill it out as much as possible. If you had the capacity to mail them a list of their diagnoses and medications as well, that would be very useful. (This was feedback we received from patients).
3. For a patient to be able to enter this information electronically themselves they would have to be registered in order to create a new Shared Care Plan.
We would have to eliminate the face-to-face encounter in order to accomplish this. Hopefully, the clinics would “know” their patients and “whom” they were mailing it to. (The thought of lost mail or error in delivery may mean we should consider not sending their list of medications or diagnoses).
4. The patient would either mail it back to the clinic or they could bring it in at their next office visit.
5. This paper electronic version of the Shared Care Plan would be entered into the computer for all patients that needed assistance. “Who” would do this work would still need to be determined. Only if patients could be registered by the clinics prior to the mailing, could they then enter it themselves if they were capable and had computer access.
6. Schedule a 1 hour office visit with their Primary Care Clinician /ARNP/PA.
You will need ~ 30 minutes to edit and review an existing electronic Shared Care Plan and address any concerns. A one-hour visit is what it will take to do a history and physical examination, reconcile an accurate medication list, review and update an existing Shared Care Plan.
This would promote continuity of care, medication safety and accuracy, promote patient self-activation and management, and increase physician, staff, and patient satisfaction.
7. This would also promote open access to care when a patient wanted or needed an appointment as it has been proven that utilization decreases when a patient sees their own PCP /Specialist who is most familiar with them.
8. Reimbursement still needs to be worked out for this comprehensive visit.
Today’s office visits for chronic care that may have 15 minutes at some facilities to
address complex, multi-system failure concerns are not able to treat the patient as a whole and deliver patient –centered care. This is one reason why patients return frequently and subsequently create increased demand for care with diminished access.
It is time for a new world in healthcare – we need to do the work smarter not harder.
