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.
- Determine who has responsibility for each step of the planned visit.
- Obtain senior leader support for training staff in new roles and tasks.
- Identify who will do the training.
- Identify resources, training material, and tools.
- Offer opportunities for the staff member being cross-trained to shadow or observe the staff member doing the procedure (e.g., foot exam).
- Train providers, medical assistants, nurses (e.g., self-management goal setting and follow-up), and periodically check staff competency with tasks.
- Use standing orders for labs.
- Develop standing orders for nurse or dietician.
- Educate nurse and dietician on use of standing orders.
- 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.