Self-Assessment: Structures and Processes

Optimal outcomes are more likely when a provider and/or practice:

  • Provides team based care,
  • Has processes that are proactive in nature,
  • Uses decision support within provider workflow to both decrease variation and increase effectiveness,
  • Engages patients in a manner intended to help them manage their own condition, and
  • Uses information systems to find and fix gaps in care.

This type of care delivery system is described within Ed Wagner’s “Chronic Care Model”1 and forms the basis of a patient centered medical home.

To be more descriptive and representative about what an idealized, future-leaning practice that has been transformed actually looks like, consider the following scenario. While reading through this hypothetical scenario, begin your own mental self-assessment by reflecting on your own structures and processes.

Some elements to consider when providing patient care include:

  • Use evidence-based guidelines such as U.S. Preventive Services Task Force (USPSTF) tools to monitor and provide best care for patients.2
  • Establish in your practice workflow a pre-visit planning process that allows for some of the work to be done prior to seeing patients, such as reviewing core services and tests required by the patient and including a checklist that staff can review prior to each patient’s visit. This will allow staff to identify opportunities to educate patients about basic diabetes care, including an eye exam, foot exam, history of tobacco use, and comorbid conditions such as depression, prior to their appointment.
  • Review patients’ records to identify their current problems and find resources and education to provide the patient with support and identify his or her risk stratification.
  • The patient with depression, on insulin, and with poor control is at risk for stroke and myocardial infarction (MI). By having a proactive approach, reviewing opportunities to engage the patient in his or her care, setting up small, achievable goals with the patient and identifying barriers to treatment, the provider can work more closely with this patient and bring him or her back more frequently to slowly work on the different areas to gain better outcomes.
  • This approach has defined roles and uses a team approach, rather than relying on the physician’s discretion, to recognize all of the issues that can be overlooked or missed in a 15-20 minute office visit. It is also important to order labs and other tests—including the patient’s A1C—and assess cardiovascular risk.
  • Review all preventive guidelines that have not been applied with the patient to provide more comprehensive diabetes care.
  • Program the needed requirements into an electronic health record to capture key preventive measures for each patient with diabetes. Document the date and result of the last eye exam into a flow sheet to track improvement. Record areas of concern for each patient prior to their appointment as well as during their appointment.
  • Work with patients’ health plans or community services for chronic care management to learn how these programs might be able to help patients.