Delivery System Design:
Use the Registry to Proactively Review Care and Plan Visits
See the Clinical Information System section for more information on establishing a registry.
- 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 the registry to prepare for individual planned visits. The provider care team:
- Identifies HIV/AIDS patients coming in for an appointment the next day or week.
- Looks at registry data and identifies needs on a flow sheet or visit note.
- Plans the 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.
- Use pre-printed progress notes, tools, and charts. Use information systems to access updated disease management information. (See Clinical Information System.)
- Use the registry as a reminder to review HIV self-management goals at all visits (not just HIV-related visits).
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Schedule regular staff time for population review. Look for areas of need, e.g., vaccination, PPD, lab tests.
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Train staff members in scheduling proactive visits.
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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 walkin/ 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’re still ahead of the game!)
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Flag outdated contact information so that staff can correct it in administrative records as soon as possible.
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Create a system for initiating or updating selfmanagement goals.
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Include list of referral resources on flow sheet.
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