The Three Phases of the Diabetes Care: Pre-visit, Intra-visit, Post-visit
Diabetes care can be organized into three phases: pre-visit, intra-visit, and post-visit. Opportunities exist during each phase to introduce practice changes that can help engage and support patients in their diabetes care and management. Health care teams can optimize diabetes encounters by taking a planned, continuous improvement approach to visits, which includes pre-visit preparation (by both patients and practices), intra-visit coordination (among practice team members), and post-visit follow-up (among the practice team and with patients).
Pre-planning for diabetes visits helps ensure that both patients and practice staff are prepared for diabetes visits.1 Ideally, pre-visit preparation starts at the end of the current visit. Patients schedule appointments for their next visit, which, if not at goal, may be in three months, and arrangements are made for A1C labs to be drawn just prior to the next visit or at point-of-care, along with other labs (e.g., lipids), to ensure an opportunity for timely treatment adjustments. This way, the provider and patient have all the relevant information at hand to review, discuss, and adjust therapies (e.g., increase medication doses) at a face-to-face visit. Compared with trying to coordinate a time to review the lab results a few days later, this approach saves time and allows for better communication between the patient and provider.
The process of pre-visit preparation involves the following steps:
- Proactively identify patients who are due for diabetes visits.
- Contact patients with clear instructions.
- Prepare patients to be active participants in their diabetes visits.
- Use standardized encounter forms to organize information prior to the visit.
- Integrate strategies for relaying information to practice team members prior to patient encounters.
Practice teams now have access to sophisticated tools that allow them to systematically identify patients who are due for routine diabetes visits and may benefit from additional medical care, like immunizations. Population management techniques can equip practice teams with important and timely information about their patient population to streamline this process.
This step includes notifying patients who are due for an appointment and informing them of specific tests (e.g., A1C), assessments, or other requirements to complete prior to the visit. If the patients have not completed their visits with the diabetes educator, diabetes self-management education referrals can be sent and patients encouraged to see the diabetes educator. Medicare provides 10 hours of diabetes education during the first year a patient is diagnosed with diabetes and covers 2 hours per year every subsequent year. Working with a diabetes educator provides an effective opportunity for the patient to discuss and be guided regarding meal planning, physical activity, glucose monitoring, problem-solving, and coping, rather than relegating these topics to the already full provider visit, which may be needed to adjust medicines, review labs, and address comorbidities.
Patients who come to an appointment ready to discuss their concerns and questions are much more likely to engage in the diabetes visit, feel satisfied with their experiences, and make informed decisions regarding their diabetes management. Health care practices can help their patients prepare for their visits by requesting that patients complete a diabetes assessment form about their diabetes-related behaviors and goals, or by sending them diabetes-related decision aids in advance of an appointment. These are some examples of how to prepare a patient for a visit.
Standardized encounter forms can help the health care practice gather patients’ information prior to their visits. Forms may be paper copy or integrated into the electronic health record (EHR), depending on a health care practice’s operating system. When patients arrive for a visit, health care team members can review patients’ concerns and goals for the visit, perform additional screenings or assessment of diabetes-related behaviors, and conduct medication reconciliation. These activities can also be performed before patients arrive for a visit. The ultimate goal is to minimize the amount of information that the physician must gather during the diabetes visit, allowing the physician to focus on the patient’s key issues. Labs should be drawn so that they are available at the time of the visit to improve communication and save time. If self-monitoring of blood glucose (SMBG) levels are recorded, upload these onto the patient portal.
Another strategy for facilitating productive and focused encounters is to hold brief pre-meetings, often in the form of team huddles, which allow health care teams structured opportunities to review key data and information that will be needed to frame the patient visit.
The diabetes visit should be guided by the physician, making sure that the patient’s concerns and needs are addressed and relevant clinical and behavioral data are obtained. Pre-visit labs should have been drawn and available. Relevant recent labs should also be available during the visit. This allows the physician and patient to discuss A1C values and medication adjustments in-person and eliminates the very time-consuming task of calling a patient and adjusting medications after a patient has left the office. Meaningful diabetes encounters use proven approaches to encourage patient engagement (e.g., shared decision making and motivational interviewing), allow for patients to play a role in developing their treatment plans, and integrate education and goal setting tailored to patients’ specific needs and preferences. Vaccines due can be administered via standing orders. Point-of-care alerts, clinical decision support tools, order sets, and standardized education can help facilitate the diabetes visit. Innovative approaches, such as “teamlet” models and “scribing” can help improve the efficiency and effectiveness of the diabetes visit.
It is important to develop a system for the end of a patient encounter that supports careful review of the after-visit summary to ensure that patients understand and can execute their care plans and goals, including a plan to order labs just prior to their next visit. This review should be supplemented with patient education materials and referrals to community resources as well as referrals to specialists (e.g., certified diabetes educators), as appropriate, to aid patients in their diabetes self-management and support at recommended intervals.2 It is particularly important that patients leave the office with a clear understanding of medication management, especially for newly diagnosed patients and those with medication or therapy adjustments. The National Diabetes Education Program’s (NDEP’s) Promoting Medication Adherence in Diabetes has more information on this topic. Referrals to diabetes education programs may be arranged every year.
A system should also be in place for communicating with patients between visits. If pre-visit labs were not drawn, and new lab results are obtained at the current visit or soon after, this may include calling patients to review lab results and assessing how patients are doing with their self-management goals. Intra-visit communications may be offered to all patients with diabetes, or health care practices may choose to focus specifically on patients who are not at goal for a particular clinical value (e.g., elevated A1C, lipids, or blood pressure). Health care practices can use population management strategies or flow sheets3 to identify and track patient progress and guide communication decisions. To make inter-visit communications manageable, practices should streamline the process, relying on automated notifications, patient portals, and/or dedicated team members (e.g., care coordinators) to facilitate the process.