Marie T. Brown, MD, discusses the benefits of pre-visit planning and shares strategies to help ensure that providers and patients are prepared to assess and address diabetes management during office visits.

Q: How do health care professionals, medical practices, and patients with diabetes benefit from pre-visit planning?

A: Pre-visit planning is a process where you plan for patients’ future appointments at the conclusion of the current visit, arrange for what should happen between this visit and the next visit, and huddle with your team prior to the patient’s next visit. With pre-visit planning, everyone is prepared to make the most meaningful use of everyone's time during the office visit.

When it comes to providing care for people with diabetes, you are often caring for someone with numerous comorbidities. Your patient may be cared for by several doctors and prescribed numerous medications. A key component of pre-visit planning is making sure that everything the patient and provider need to assess diabetes management is on-hand during the office visit. This requires the patient to have lab tests a week or so before the visit so that any changes in treatment, such as medication changes, occur face-to-face to ensure optimal communication.

Q: During a patient visit, how can health care professionals and patients plan for the next visit?

A: It’s important to have a conversation with your patient about the next visit at the end of the current visit. For instance, if your patient is not reaching his or her goals for blood glucose, you might suggest scheduling office visits every month until things start to improve. If your patient is reaching his or her blood glucose goals, he or she may only need to be seen once or twice a year. The vast majority of patients who have diabetes are seen every 3 months. It’s important that the patient understands and agrees with the plan, too.

In addition to talking about the next visit with your patient, let your patient know which lab work needs to be done before the next visit and order the necessary pre-visit lab tests. These tests can be done at a laboratory closer to the patient's home or during another visit your patient may have scheduled at your office or center for another reason. If a second visit is too much of a burden, point-of-care testing would also provide the needed lab test results.

Some doctors use a pre-visit planning checklist. Once a year, the checklist may include annual tests or referrals such as a lipid test, albumin creatinine ratio, urine test, a referral for a diabetes educator, a referral to an ophthalmologist, and so on. For the checklist, you can use order sets in electronic health records (EHRs) or use paper checklists that are handed to your team.

Q: What planning is needed in the days or hours before a patient visit?

A: The team should sit together to plan what a pre-visit planning checklist should look like. The main goal of pre-visit planning is to deliver quality efficient patient care. If you’re just beginning to do this, the process should involve the entire team so that everyone on the team understands, “What’s in it for me?” We don’t want pre-visit planning to shift the burden from one team member to another. With pre-visit planning, patients will be more likely to be seen on time, which is a much more pleasant experience for everyone. If everyone on the team understands that one of the goals of pre-visit planning is to make sure that the office stays on schedule, then the receptionist knows that they are going to have more pleasant patients in the waiting room. The team members, such as the medical assistant or nurse, will also have more time to develop a relationship with the patient, and they’ll be able to get out on time with a feeling of a “job well-done.” Care gaps such as immunizations and cancer prevention are addressed prior to the office visit and orders entered or “pended” by the team. The front desk team members can help by printing lists of patients with care gaps so that the clinical team can address them during “downtime.” 

Usually, a day or two before the patient visit, a team member will look at the notes in the EHR to make sure lab test results are up-to-date and remind patients if they still need to get their blood drawn. This review helps identify gaps in care, such as needed immunizations, annual lab tests, preventive health screenings, or referrals to a diabetes educator or other health care professional. This is time well spent because a half hour one day can save two hours the next day.

The pre-clinic care team huddle is also part of pre-visit planning. At the start of the day, huddle with the whole team to look at the schedule and get an overview of what the day is going to look like. This is an opportunity for team members to share information that could affect the day. For instance, someone might need to take a phone call or need a longer lunch break to handle a personal matter. It's also important to look at all the patients scheduled for the day and identify, for example, who may need a larger room because they use a wheelchair or have family members accompanying them. This is an opportunity to find out who might require an interpreter. You might find that there is a patient on the list who is routinely, for many reasons, always late—maybe due to public transportation delays—and planning for that disruption is important so that you minimize the effect on the schedule.

The American Medical Association (AMA) STEPSforward™ module on pre-visit planning, authored by Dr. Christine Sinsky, is a free resource that outlines 10 steps to pre-visit planning and offers tools including checklists as well as case studies. STEPSforward™ also offers a module on developing an efficient team-based approach to managing diabetes.

Q: How can health care professionals engage patients in pre-visit planning? What technologies can help?

A: Having patients take ownership of completing blood tests prior to the visit is important, because patients often prefer to discuss medication changes face-to-face. It also helps visits start and end on time, and helps patients achieve their goals more readily.

Organizations can use technology to develop automated reminders for patients. Patients can also use online patient portals to upload their blood glucose or blood pressure logs and review their medications before a visit. Sending educational materials also streamlines the visit.

Engaging patients in pre-visit planning continues in the waiting room. For example, before a patient visit, a receptionist may print out a list of the patient’s medications and ask the patient to review the list and provide feedback.

Asking patients to write down their priorities for the visit while they’re in the waiting room saves time, as well as ensures the patients’ needs are met. They may need a handicapped parking sticker or a referral to a podiatrist. The receptionist or medical assistant can begin addressing some of these issues while the provider can address issues that require higher decision-making skills, assess adherence, and build a trusting relationship with the patient.

Q: Are there specific examples of pre-visit planning strategies that have improved your visits with patients who have type 2 diabetes?

A: Absolutely. Many of my patients see the diabetes educator four times a year, usually a week before they see me. Recently, I saw a patient with newly diagnosed diabetes following their first visit with the diabetes educator, where they had learned how much sugar is in a 20-ounce bottle of soda. Just by cutting out soda intake, which was one soda a day, the patient began losing weight. She was excited!

At check-in, patients are handed a list of their medications and asked to circle those that need refills, cross out medications they are no longer taking, and add a question mark to medications they don’t think they need.

In our patient portal, patients can see their test results, and they know what their A1C is before I see them. So, they're prepared to hear a congratulatory message or have a conversation about adherence, diet, or the need to escalate therapy. They’re prepared to be part of the discussion about next steps and goals. Agreeing on the A1C goal and ensuring the patient understands and agrees with the goal is of paramount importance. The same is true for blood pressure goals. Often, providers assume that the patient understands the goals of therapy.

Q: Are there any other aspects of pre-visit planning that health care professionals should consider?

A: It’s important to start small so that you're successful. For instance, some organizations have done pre-visit planning for the last three or four patients of the day, since that is when the clinic is running late and staff is tired. Once the team sees that doing pre-visit planning for the last few patients of the day saved everybody time, usually one of the team members will say, “Why don’t we do this with all of our patients?” Some organizations start pre-visit planning for all patients and close all care gaps all at once. This takes planning and more resources (time for training, protected time to do the planning, and possibly more staff).

My advice is to choose a small group of patients to start with pre-visit planning. You could do this with patients over 70 years old, or just for patients with diabetes. See how successful it is, what you've learned from it, and if you're going to adopt it or adapt it.

Start with what the team values most and use the Plan-Do-Study-Act cycle: plan it; do it; study the effect; and adopt it, adapt it, or abandon it and try something else. Pre-visit planning will look different at every organization, depending on the organization's resources and the team’s level of interest.