
Delivery System Design:
Use the Registry to Proactively Review Care and Plan Visits
- To institute proactive care, review the registry to identify population-based needs (e.g., assessments, follow-up) and plan visits to meet those needs.
- 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.
- Use care flow sheets, charting templates or similar tools to guide care and follow-up.
- Review Asthma Action Plan (AAP) at all visits, not just asthma visits.
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