IHI.org - A resource from the Institute for Healthcare Improvement
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Delivery System Design:
Use the Registry to Proactively Review Care and Plan Visits
  1. To institute proactive care, review the registry to identify population-based needs (e.g., assessments, follow-up) and plan visits to meet those needs.
  2. Use planned visits.
    • Provider care team identifies asthma patients coming in for an appointment the next day.
    • Provider care team looks at registry data and identifies needs on flow sheet or visit note.
    • Provider care team plans visit, including who will perform assessments, make referrals, and generate self-management goals.
  3. Use care flow sheets, charting templates or similar tools to guide care and follow-up. 
  4. Review Asthma Action Plan (AAP) at all visits, not just asthma visits.

Tips
  • Schedule regular staff time for population review. Look for areas for improvement, e.g., use of anti-inflammatory medications, too few symptom-free days, or no Asthma Action Plan.
  • Train staff members in scheduling proactive visits.
  • Use daily huddles for staff to communicate patient needs. (This technique is incredibly useful for improving the efficacy of scheduled visits and ensuring that all patient needs are addressed. The huddle can enhance walk-in/urgent visit management by decreasing the time needed for scheduled visits. If this is the ONLY thing clinics do with regard to Delivery System, they are still ahead of the game!)
  • Flag outdated contact information so that staff can correct it in administrative records as soon as possible.
  • Have a system for initiating an Asthma Action Plan if one is missing, or updating it if it is out of date.
  • Schedule asthma planned visits to coincide with school and athletic physicals (in August).
  • Place Asthma Action Plan on top of vital signs sheet.