Define Roles and Distribute Tasks Among Team Members to Provide Better Care for People with Chronic Conditions

Improving Chronic Care: Delivery System Design
To provide better care for people with chronic conditions, assign roles, duties, and tasks for planned visits to a multidisciplinary care team. Use cross-training to expand staff capability.
  1. Determine who has responsibility for each step of the planned visit.
  2. Obtain senior leader support for training staff in new roles and tasks.
  3. Identify who will do the training.
  4. Identify resources, training material, and tools.
  5. Offer opportunities for the staff member being cross-trained to shadow or observe the staff member doing the procedure (e.g., foot exam).
  6. Train providers, medical assistants, nurses (e.g., self-management goal setting and follow-up), and periodically check staff competency with tasks.
  7. Use standing orders for labs.
  8. Develop standing orders for nurse or dietician.
  9. Educate nurse and dietician on use of standing orders.
  10. Use registry to identify patients who need labs and send letters to patients requesting they get them.
  • Beware of relying on volunteers: they should be under the supervision of a paid employee so that if the volunteer is unable to do the task (e.g., follow-up phone calls), the supervisor is aware and can make other plans.

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