Prepare for upcoming patient visits by reviewing a patient's record (particularly issues occurring since the last visit) and identifying issues that should be addressed either before or during the patient visit. Communication between team members may be electronic messages, e-mails, or notes in a patient record. The following steps are options to help implement communication between team members when preparing for patient visits:
Convene an internal communications team
Choose a lead clinician, referral-tracking staff member, clinical nurse, and scheduler to join together as a team to develop a process for internal communication among all team members. The lead clinician may be a physician, mid-level practitioner, nurse, or practice manager. This team will lead the practice in implementing team-based care communications.
6b. Create policies and procedures for internal communication
Document a policy and procedure for structured preparation of upcoming patient visits. This should include identifying critical patient needs to be addressed either before or during the visit. In the policy, demonstrate how communication occurs regularly by including samples of meeting minutes, agendas, or memos/e-mails to staff. Team meetings should be held weekly (at a minimum), to discuss scheduled patients and identify whether any pre-visit information or resources will be needed to maximize efficiency during the office visit. For example, the team may need to contact a patient, obtain lab reports, review prior records, review screening reports, or obtain and review diagnostic studies.
6c. Team huddles
Short team meetings or "team huddles" should be conducted once or twice a day; ideally prior to the start of the morning session and afternoon session in the practice. When bringing the team together, select a place that is convenient and suitable for open discussion of patient information.
The purpose of the team huddle is to review the patient schedule for the next segment of the day and prepare for potential challenges, such as patients with complex health needs who require additional time or staff support. In general, team huddles should be brief (ie, less than 10 minutes in duration), and focused on planning tasks related to the next set of patients. In general, the team should discuss patients with complex conditions, patients who have been recently seen in the Emergency Department or hospitalized, patients who are often late or have high service needs, patients who are missing recommended preventive care services, or patients who will require additional time or attention from staff.
The team huddle could also be used to briefly review the previous day, and to discuss hospitalized patients or other patients who require specific follow-up. The team should decide who will provide any necessary follow-up and the timeframe the follow-up should take place. Team huddles should be led and monitored by the lead clinician for frequency and compliance among staff members.
6d. Post-visit communication with patients
Have systems in place to identify patients telephoning with concerns that problems treated within the past 48 hours have persisted or worsened. Identify return visits and Emergency Department visits for the recently treated problem. Establish policies to verify that this information is shared with clinicians and addressed rapidly.