The objective of pre-visit planning is to help the patient and physician conduct the face-to-face visit more effectively by gathering and organizing information ahead of time so they can devote more attention during the visit to interpreting, discussing, and responding to that information.
Pre-visit planning takes place in several steps:
1. Plan forward, or “The next appointment starts today.” 5 The most efficient form of pre-visit planning begins near the end of the previous visit. As the visit draws to a close, the physician and patient decide on next steps, such as planning any lab tests that might be needed before the follow-up appointment. The physician is already familiar with the patient's conditions and medications, so it should take very little time to identify the appropriate tests for the next visit. The patient then may schedule these appointments immediately instead of having to remember to call back in several months to set them up.
In our practice, we use a checklist to help us plan for the next visit. The checklist is part of a form that also includes the date of the patient's last annual exam as well as any upcoming appointments and labs that are already scheduled. This format allows the physician to put today's care and the next visit's care within the context of the patient's ongoing care. The checklist features lab and other test options in three sections: those to be done before the patient leaves today; those due before the next follow-up visit; and those due before the next annual visit. The patient is then given the option at check-out of receiving an automated reminder phone call, text message, or letter closer to the time of the appointment. (The "Post-appointment order sheet" is available in the FPM Toolbox).
In an effort to be more patient-centered, we've also found that asking the patient when he or she would like to return is an effective way to share decision-making and give patients an active role in their own care. We also believe this approach, combined with the reminder system and pre-visit labs, have helped lower our no-show rate, which is less than 4 percent.
2. Look back. Some practices do not begin pre-visit planning at the end of the current visit. Instead, it starts a week or so before the next visit when a nurse or other staff member looks back over a patient's record and orders any tests indicated by protocol based on the patient's conditions or medications, as well as any instructions the physician left in his or her documentation from the previous visit. Practices that rely on physicians to enter future orders into the electronic health record (EHR) on the day of the visit will sometimes also employ this “look back” process by the clinical staff. Physicians may feel they cannot spare extra minutes at the end of the visit inputting orders when other patients are waiting, so the look-back process ensures the work has been done.
Reviewing the patient's record outside of the office visit requires more time than planning forward, but it is still more efficient than not doing any pre-visit planning.
3. Pre-visit lab testing. Pre-visit lab testing saves time, improves patient engagement in health management, and reduces the amount of work needed to report and respond to results. Some practices arrange for patients to come in several days before the appointment for lab testing. Others arrange for patients to have their blood drawn 15 minutes to an hour before their scheduled appointment and then use point-of-care testing or rapid turnaround of standard lab testing. In both cases, the goal is to time the tests so that the results are available to the patient and physician at the face-to-face visit.
By having the results available during the appointment, patients can be part of the ensuing decision-making and are more likely to adhere to the treatment recommendations than if they received those recommendations later by phone or letter. In addition, the physician and patient can avoid playing phone tag or engaging in several rounds of email after the visit to resolve unanswered questions. One practice found that pre-visit labs saved $25 in overhead per patient visit. 6
Pre-visit labs can also aid safety. Because patients are able to review their test results together with their physician at the appointment, it is less likely that an important result will be overlooked or lost in the system.
4. Pre-visit phone call. Calling the patient ahead of his or her visit can help the clinical team prepare more thoroughly by clarifying the patient's agenda, anticipating any special needs, and completing many of the tasks usually performed during rooming, such as reviewing medications or screening for depression or falling. Some practices reserve pre-visit phone calls for complex patients. A pharmacist or pharmacy technician may also call these patients for in-depth medication reconciliation. In some cases, this process is aided by access to an all-payer claims database, which staff can use to see what medications the patient has actually filled. You can identify and address nonadherence to medication in a non-judgmental way with this approach.
5. Visit preparation. On the day of or the day before a visit, the medical assistant or nurse can do a quick review of the patient's record to see what needs the patient may have during the appointment. For example, they can identify if the patient needs an immunization, a cancer screening, or other prevention measures and close these “care gaps” during the rooming process. Conducting visit prep can be an effective tool in panel management and can positively affect the health of the entire patient population.
6. Pre-visit questionnaire. A pre-visit questionnaire is a list of questions the patient completes either on paper in the waiting room or through an online patient portal from home. See the questionnaire our practice uses.