Delivery System Design:
Assign Roles, Duties, and Responsibilities for All Tasks Within the Delivery System Design, Especially for Planned Visits to a Multidisciplinary Care Team
- Determine who has responsibility for each step of the planned or acute visit and for follow-up. Determine a timeline for tasks.
- Train staff for new roles and responsibilities detailed in the new delivery system design.
- Obtain senior leader support for training staff in new roles and tasks.
- Identify who will do the training.
- Identify resources, training material, and tools.
- Use cross-training to expand staff capability. The staff member being cross-trained should shadow or observe the staff member doing the procedure (e.g., case manager crosstraining with a psychologist to learn how to conduct a brief depression screen). Other areas for cross-training include:
- Conducting a quality of life/psychosocial evaluation
- Adherence questioning
- Updating medications
- Updating contact information
- Blood-drawing
- Setting self-management goals and contract
- Train providers, medical assistants, and nurses in tasks such as addressing medication adherence, nutrition assessment, self-management goal setting and follow-up, and periodically check staff competency with all tasks.
- Use standing orders for appropriate medication refills and immunizations.
- Ensure easy access to multiple disciplines and services through the use of the team concept (one-stop visit).
- Hold multidisciplinary case conferences before and after patient visits.
- Hold clinical rounds to discuss lab results, medication changes, etc.
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