Putting all your skills together into an efficient visit

Creating value for the patient

Learning ObjectivesKnowledge of “micro-skills” does not always

translate into effective use of themPatients who have not “read the book” about

how visits can be most effective can often frustrate both efficiency and effectiveness

Strategies for keeping visits on trackPractice scenariosFocus for chart reviews for next month

FP is the specialty of SynthesisSubspecialists are experts at analysisFPs have consistently delivered better value

because we emphasize synthesisAmerican culture celebrates analysisValue is derived from synthesis – and is

rewarded in some professions, e.g. engineering & architecture

PCMH is seeking reimbursement for demonstrated excellence in synthesis

It’s not the patient’s faultwhen visits break down & we get frustrated!Other specialists focus visits by limiting their range

of services & with staff, insurers, and referral sources prepping patients to focus on one limited service/visit

How can we be the specialty of breadth and not end up with rambling visits?Team approach to setting “Today’s agenda”Micro-skills that keep the patient “on task”Prioritization on things you can make betterPlanning care over timeSizing the visit(s) to maximize benefit and payment(s)

Teamwork Everyone needs to know the “sizes” of E&M

servicesEveryone needs to know when & how visits

can be extended or truncatedHow the scheduler can helpHow the receptionist can helpHow the nurse can helpWhat the provider must do to make it

happen!

Keeping the patient “on task”Confirm the agenda after initial greetingsConditional acceptance of problematic agendasComplete histories one CC at a time in priority order

Truncate history taking 1/3 of way through visitDo problem-focused PE (even if EPF, D, or C by

documentation compliance definitions!)Take time to get diagnoses & orders right in ezSOAP

Have “training phrases” that teach patient importance Summarize visit at end and what you have planned

Summary will teach patient to focus better each visit

Covering priorities creates valuePrioritize CCs while negotiating Today’s AgendaLimiting number of priorities to the “size of your

box” teaches patient what priorities mean!“Even Borderlines can learn to prioritize!”Prioritizing long, but important, agendas means

more frequent visits!Prioritizing long agendas including trivial

problems means empowering the patient in self-care!

More frequent primary care visits decreases need for more specialists:creating value for insurersrequires patient-centered explanation andspecialist-centered political skills!

Planning care-over-timeEvery patient leaves with a plan for follow-up

Complex care may have plan for multiple servicesPriorities not dealt with need plans also

Patient does not need to follow up for trivial problems

Many times the best follow up is to wait for symptoms to “declare themselves”Patients need to understand that you are doing thisThey need to know their responsibility to report

“declarations!”Patient should always know when their next

primary preventive services visit is scheduled – until primary prevention is no longer needed!

One size does not fit allOne-size-fits-all appointments does not mean

one-size-fits-all services!“Huddle” with your nurse before set to “size”

appointmentsNurse frames type of visit when asking for patient’s

agendaProvider gives “sign posts”

when changing frameswhen planning future follow up

What to do when you are running late“Huddle” at end of set with nurse/preceptor to learn

from experience

Practice scenarios – Case 1Patient says s/he needs refills of 6 prescriptions

for 3 chronic conditions at end of visit for a “cold”How do you salvage today’s visit?

What “sign post” do you use to signal “foul?”How much additional history do you obtain?What do you document to get paid for the extra

work?How do you communicate why you “died in the

room?”What do you do to decrease the chance this

patient will “pull” this in the future?

Practice scenarios – Case 2Patient presents with acute back pain (he looks

& acts as though in acute pain). Your chart biopsy shows that he is 4 months past planned f/u of hypertension, BP 142/94. When you ask if there is anything else, he says he would like a prescription for Viagra.

There are four 99214 “frames” you could offer for this visit. What are they?

What approach would you recommend? How would you plan F/U of the remaining

problems?

Practice scenarios – Case 325 y.o. presents with 5 trivial problems. Your

chart biopsy reveals last Preventive visit billed > 1 year ago.

What is the best way to frame this visit for reimbursement?

When do you plan to see the patient again?How do you teach the patient so that future

visits will be productive for the patient (and you!)?

Practice focus for next monthIs there a “narrative thread” connecting each

CC with an Assessment?Have you documented enough history & PE

for each problem for good clinical care?Have you avoided “naked diagnoses?”