Use Planned Interactions to Support Evidence-Based Care for Chronic Conditions

Improving Chronic Care: Delivery System Design

Obtain senior leadership support for planned visits, expecially to resolve potential reimbursement issues relating to group settings.

  1. Block time for providers in advance.
  2. Use registry to identify patients in need of visits.
  3. Have promotoras, community health workers, volunteers, or appointment staff call and schedule patients for visits.
  4. Train staff in planned visit approach. A planned visit should contain an assessment, review of therapy, review of medical care, self-management goals, problem solving, and follow-up plan.
  5. Assemble a patient visit team (provider, certified diabetic nursing assistant, promotoras, intake worker, lab, immunization, and referrals).
  6. Use group visits to deliver care. A group visit brings together 8 to 20 patients to deliver medical care in a group setting; all patients are in the same room, and providers come to the group to take vital signs, discuss issues, and answer questions.



  • Have planned visits be part of the organization's stated philosophy of care.
  • Be cognizant of cultural diversity in your patients.
  • Make group visits multidisciplinary, including dental, podiatry, and ophthalmology.
  • Try holding group visits at homeless shelters, housing or faith-based organizations.



For Diabetes Patients:

  1. To institute proactive care, review the registry to identify population-based needs (e.g., eye and dental exams) and plan group visits, mailings, fairs, and reminders to patients to meet those needs.
  3. Use planned visits. The provider care team:
    • Identifies diabetic patients coming in for an appointment the next day.
    • Looks at registry data and identifies needs on flowsheet, visit note, or encounter note.
    • Plans visit, including who will draw labs, make referrals, and do self-management goals.

  5. Use care flowsheets, charting templates, or similar tools to guide care and follow up.



  • Use the reports from the registry that can answer the many patient care-related questions (e.g., "List all patients who have not had an HbA1c in 6 months".)
  • Schedule regular staff time for population review.
  • Look for areas for improvement, e.g., smoking cessation, blood pressure control, and foot exams.
  • Use daily huddles for staff to communicate patient needs.
  • Use daily care team meetings to prepare for the day's planned visits.
  • Consider "one-stop shopping" appointments with multiple providers for patients with many overdue needs.
  • Use mail merge software for mailings/reminders.

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