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Pre-visit Planning Saves Time

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Learn about some pre-visit planning strategies that can make office visits more efficient, productive, and meaningful for both the health care team and patient.

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.

In many clinics, the available A1C is from 3 months prior—too long ago to make any adjustments in a treatment plan. You order an A1C, receive the results the next day, and now you need to reach your patient to adjust therapy based on the most recent A1C results. Attempting to reach them by phone or email causes delay and needless inefficiencies. If only you had the needed results during the patient visit!

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.

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Applied techniques for putting pre-visit planning in clinical practice to empower patient-centered care in the pandemic era: a systematic review and framework suggestion

Marsa gholamzadeh.

1 Health Information Management Department, School of Allied Medical Sciences, Tehran University of Medical Sciences, 5th Floor, Fardanesh Alley, Qods Ave, Tehran, Iran

Hamidreza Abtahi

2 Pulmonary and Critical care Medicine Department, Thoracic Research Center, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran

Marjan Ghazisaeeidi

Associated data.

The study involves only a review of the literature without involving any data.

One of the main elements of patient-centered care is an enhancement of patient preparedness. Thus, pre-visit planning assessment tools was emerged to prepare and involve patients in their treatment process.

The main objective of this article was to review the applied tools and techniques for consideration of putting pre-visit planning into practice.

Web of Science, Scopus, IEEE, and PubMed databases were searched using keywords from January 2001 to November 2020. The review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Then, qualitative analysis was done to suggest an appropriate framework by mapping the main concepts.

Out of 385 citations were retrieved in initial database searches, 49 studies from ten countries were included. Applied pre-visit techniques can be classified into eight categories. Our results showed that almost 81% of studies were related to procedures that were done between each visit, while 42% of articles were related to before visits. Accordingly, the main approach of included articles was patient preparedness. While 38 studies reported this approach is effective, three studies reported the effectiveness of such tools as moderate, only two articles believed it had a low effect on improving patient-centered care.

This survey summarized the characteristics of published studies on pre-visit planning in the proposed framework. This approach could enhance the quality of patient care alongside enhancement patient-provider communication. However, such an approach can also be helpful to control pandemic diseases by reducing unnecessary referrals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06456-7.

In the information-driven care era, although the ultimate goal of health systems is still improving the quality of patient care, the patient care model has shifted from personal responsibility to participatory medical decision-making [ 1 ]. Thus, the responsibility of the patient’s health is no longer solely with the physician. On the other hand, the role of the patient in promoting his health status cannot be denied [ 2 ]. Hence, the patient-centered care (PCC) model was introduced to show the participatory role of the patient and other health care providers in the process of treatment and patient care [ 3 – 6 ]. Since the PCC idea was introduced, various definitions and models have been proposed to distinguish the main elements of this model [ 5 , 7 – 12 ]. Up to now, the best model that has been able to explain the main components of such a care model is the model presented by the Picker Institute [ 13 ]. This model consists of eight parts that outline the factors affecting the achievement of an optimal patient-centered care model [ 5 , 12 , 14 ].

One of the main elements of the PCC approach is respect for patients’ value by preparation of patients for each visit [ 6 ]. Sometimes patients have to spend more time in the waiting room than in a physician’s office [ 15 , 16 ]. Also, in each appointment, especially in the first visit, more than 5 min should be devoted to determining who the patient is, what is his problems, which drugs she/he used, what is his/her medical history, and so on [ 17 ]. This process is so complex in patients who have a chronic condition or patients with multiple chronic conditions with multiple medications [ 18 , 19 ]. It can be useful to prevent the spread of the disease. Limited time for each visit and patient complexity might have a negative impact on the patient-physician relationship.

In this context, pre-visit planning and visit preparation concepts have been suggested by American Medical Association (AMA) as a solution to address these challenges. It can help physicians when the patient checks in for the first time, he is already behind [ 20 ]. This term (pre-visit planning) was introduced by Sinsky et al. in 2014 to collect and organize patient data before a patient visit [ 21 ].

The purpose of pre-visit planning is to help the patient and physician to save time and improve care by gathering and organizing information in a structured way. Therefore, a health care provider can pay more attention to interpretation, discussion, and response to a patient during the visit. This idea is not just to plan ahead before each visit. Dr. Sinsky explains that pre-visit planning could include a broader concept that could generally refer to preparing the patient for a face-to-face visit more effectively [ 21 ]. The pre-visit planning concept is described in Fig.  1 as a conceptual model.

The conceptual model of pre-visit planning

However, there are various methods to apply this new approach into practice, it usually includes scheduling future appointments and preparing patients before the visit [ 22 ]. These techniques are known as pre-visit assessment tools. The use of pre-visit assessment tools focuses on involving the patient and the physician through the patient care process [ 23 ]. As it is apparent in Fig. ​ Fig.1, 1 , it can occur at end of each visit, arranging for the next visit, programming for the next clinical and paraclinical testing, gathering the necessary information for the subsequent visits, and take steps regarding the handoff of patients [ 24 ].

With pre-visit planning, patients and physicians are prepared to make meaningful use of their time during each visit. Furthermore, patients could have an impressive role in clinical decision-making regarding their treatment process [ 25 ]. Hence, several studies have focused on the power of patient-centered care to improve patient care, but no studies have been published to examine the applying pre-visit planning techniques in the context of patient-centered care. The main objective of this study is to review the consideration of pre-visit planning used in patient-centered care. Throughout this paper, the term pre-visit planning will refer to any intervention, care program, patient-centered planning, or even educational plan that is considered to prepare the patient for a face-to-face visit or improve the patient-provider relationship. Specific aims of this survey are as follows: 1) representing an overview of applied methods regarding pre-visit planning with their characteristics in published studies, 2) to investigate the published studies on applying pre-visit planning regarding clinical aspects such as type of disease, 3) to determine the effectiveness of putting pre-visit planning into routine practice, 3) providing an overview of the sample size, approaches, and collected information concerning applied methods and techniques, 4) suggesting a framework in this context.

A systematic search of four databases (Web of Science, Scopus, IEEE, and PubMed) was conducted from January 2001 to November 2020 using keywords alongside Mesh terms. These databases were selected for their inclusion of qualitative studies and health research. The keywords used in the search strategy were drawn from preliminary searches according to our study goals. Those keywords were validated and additional keywords added by checking the terms used in articles identified in preliminary searches. Boolean search strategies were described in Additional file 1 : Table A-1. Since no result was found in the IEEE database, it was removed from source databases in Table A- 1 . This systematic review was completed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist to ensure the inclusion of relevant studies [ 26 ].

Inclusion and exclusion criteria for study selection

Articles were included if they met the following criteria: 1) The focus of the study was on applying the pre-visit approach through the patient care process. 2) Population includes all of the patients with any type of disease, 3) This study covered all phases of the patient care process, 4) Published in recent 10 years and matched with the search query, 5) Limited to those published in the English language, 6) Only published articles and reviews in peer-reviewed journals were included, 7) All type of study designs, 8) Improve patient-centered care, 9) Studies that received an acceptable score in terms of quality based on the checklist. Articles excluded if they met the following criteria: 1) The title, abstract, or full text of the article did not relate to pre-visit planning, 2) Thesis, book chapters, letters to editors, short briefs, reports, technical reports, book reviews, review, or meta-analysis, 3) Non-English papers, 4) Publication that their full-text is not available.

Data screening phase

Based on our search strategy; articles were retrieved from databases. Additionally, related studies were added manually by a simple search in Google Scholar and reference checking. All of the citations were imported to EndNote software for better resource management. Then, duplicated articles were removed. In the first phase, all titles and abstracts of articles were examined based on our main objective to select relevant studies by one author (MG). A second reviewer (MGH) reviewed a sample of studies randomly. After that, the full texts of relevant studies were screened thoroughly by two reviewers (MG and MGH). If there was a disagreement between the authors in the selection of relevant studies, the final decision was made by HA. Lastly, some studies remained as eligible articles for qualitative analysis. The extraction forms were designed by researchers to manage and investigate the obtained information. To diminish bias, key subjects of articles summarized and entered into customized extraction forms based on specific classifications. Two authors (MG and MGH) independently extracted the study characteristics based on the classification. The information extracted by the researchers was re-examined to reach an agreement. The next reviewer (HA) assessed and verified the extracted information.

Critical quality appraisal

The methodological quality of the included articles was evaluated using the Qualitative research Critical Appraisal Program (CASP) tool by two authors. This instrument was used in systematic reviews frequently for qualitative synthesis [ 27 ]. It was employed for appraising the strengths and limitations of any qualitative research methodology. It was recommended for health-related researches and it is appropriate for novice researchers [ 28 ]. Critical appraisal was performed independently by two researchers.

To extract some necessary information, specific categories were considered to classify and analyze relevant articles. All of the articles were synthesized regarding general and specific domains. The general domain comprises the title, author, year of publication, journal name, type of study, the main objectives. Accordingly, the specific domain comprises applied pre-visit techniques, disease, clinic, sample size, country, outcome measures, effectiveness, and collected data. Analysis of the extracted information from eligible articles and framework suggestions were conducted based on these predefined categories.

In total, systematic literature searching of databases yielded 385 citations. Of which 99 articles were removed due to duplication. Next, one hundred and sixty-six papers were excluded after screening titles and abstracts. In the following, 72 papers were excluded after full-text reading. Finally, 49 papers are identified as an eligible article which met our inclusion criteria. The screening process for articles based on the PRISMA checklist is shown in Fig.  2 . All included papers had the minimum score (10 from 20) of quality assessment using the CASP tool. Only four papers were excluded based on quality appraisal assessment. Therefore, forty-nine articles were identified as eligible studies for qualitative analysis.

PRISMA workflow for summarizing the selection of papers process

General characteristics

All included studies are published in journals from 2001 to 2020. The trend of publishing articles in this field was following an upward trend. In terms of the type of study, studies were conducted in different designs. Most of which were clinical trial studies. The descriptive analysis regarding the type of study in the included articles is represented in Table  1 . In the following, the results of the review of studies by author, year of publication, the main objectives, the sample size, type of pre-visit planning, clinic, the effectiveness of the applied method, and outcome of using the pre-visit planning are summarized in Table  2 .

The frequency of different types of study

Summary of reviewed articles and evidence

Analysis of studies showed that the application of pre-visit planning is the most favorite of developed countries. Of them, the USA has the most contribution among other studies. After that Canada ranks second in the deployment plan is allocated to pre-visit intervention. The distribution of studies concerning the country is shown in Fig.  3 .

The distribution of studies based on their conducted countries worldwide

Different techniques for putting pre-visit into practice

The investigation showed that pre-visit can apply in different ways regarding timing, main approaches, and types. The analysis showed that different types of pre-visit techniques have been employed by authors to facilitate office visits and patient care. All of these plans can be categorized into eight different categories, utilizing an electronic pre-office checklist with 12 studies (24.5%) [ 25 , 29 – 35 , 48 , 58 , 59 , 68 ], educating patients and support them before each visit in form of online and offline source of information with 12 studies (24.5%) [ 23 , 36 – 42 , 60 – 62 , 66 , 74 ], applying an EHR-linked care program with different checklists and assessment tools with nine studies (18.4%) [ 22 , 43 , 44 , 49 , 63 , 67 , 70 , 71 , 73 ], using paper-based checklists with nine studies (18.4%) [ 45 , 46 , 50 – 52 , 64 , 65 , 69 , 72 ], preparing and assess patient with the pre-visit phone-based intervention with two studies (4.1%) [ 24 , 53 ], using self-triage or self-assessment tools with two studies (4.1%) [ 54 , 55 ], using automatic reminders and sheets with one article (2%) [ 56 ], and using pre-clinic consultation by other health care team member with one article (2%) to prepare the patient for each visit [ 57 ].

According to findings, the most favorite types of pre-visit model were related to using electronic pre-office visit checklists and supporting patients by providing them with the necessary information in the form of online and offline training. In three articles, this information was provided to patients in the form of educational websites [ 37 , 39 , 40 , 60 ], while in the other six articles, the information was provided to patients in the form of training sessions before the patient’s visit and referring to the clinic [ 23 , 36 , 38 , 41 , 42 , 61 , 62 , 66 ].

The next widely applied method was the EHR-linked care program that put pre-visit planning into practice. Ten articles used pre-visit solutions such as electronic checklists, automated reminders, decision-making tools, and reviewable forms that could be implemented by connecting to electronic medical records. In third place, there are paper-based checklists used for patient preparation with nine papers. These checklists included questions about demographic information, the main problems, medical history, general symptoms, illness history, hospitalizations, medications, family history of a specific illness, level of education, location, and questions about the patient’s lifestyle. Other solutions were used in a smaller number of articles. Regarding pre-visit counseling, only one article applied the consultation of clinical pharmacists before the office visit. This approach leads to providing the physician with better information after the initial completion of the medical record.

In terms of timing, pre-visit intervention could be conducted at a different time in the patient care process. Taken together, all of these possibilities could be categorized into four situations. It can be occurred before each visit, between visits, at the end of each visit on the current visit, and in a combination of the previous three models. Our results showed that almost 81% of studies were related to procedures that were done between each visit, while 42% of articles were related to procedures that were done before each visit. Only 10 % of studies were conducted at end of the current visit.

In terms of main approaches, the analysis of studies showed that all studies can be divided into three main categories based on the main approaches. These three approaches comprise, improving the current visit and preparing the patient for the next visit, perform some procedures for patient preparedness such as sending reminders or filling pre-visit checklists, and providing more inclusively insight about the patient for the physician before they come in for an office visit. The final analysis of the studies based on the main objectives and the timing is summarized in Table  3 . Out of 49 studies, the main approach forty-eight of articles were related to patient preparedness and enhance patient adherence to their treatment.

Results of study analysis based on main objectives and timing

Out of 49 studies, only one study did not report the sample size of their study. In total, the sample size ranged from 15 to 12,228 with a mean sample size of 1160.3877 (SD = ± 2613.799). In Fig.  4 , the distribution of studies based on sample size, year, and different techniques are represented.

Distribution of studies based on sample size, year, and different techniques

The effectiveness of pre-visit planning

Articles were also reviewed regarding the effectiveness of the applied methods. Out of 49 studies, the authors of 41 articles (83.67%) considered pre-visit planning to be effective in clinical practice. While six studies (12.24%) reported the effectiveness of these tools as moderate, only two articles (4.08%) believed that using this method had very little effect on improving patient-centered care. The effectiveness of studies concerning applied methods is shown in Fig.  5 .

Effectiveness of studies concerning applied methods

The effectiveness has been reported by researchers using various outcome measures in studies. These outcome measures reported in reviewed articles, along with their frequency and their effectiveness, are shown in Table  4 .

Outcome measures reported in these articles with their frequency and their effectiveness

Different diseases and the main reason for referral

Through this survey, the referred clinic and the main reasons for the referral were also examined in reviewed articles. In terms of the reason for referral and diseases, the most common reason for referral was related to chronic disease and general problems. The frequency of disease regarding applied methods and their effectiveness are represented in Fig.  6 . Regarding the type of clinic that was considered for implementing pre-visit planning, the highest frequency was related to primary care clinics. Next, surgical clinics had the largest number of pre-visit programs.

Frequency of disease regarding applied methods and their effectiveness

Information and collected data

To implement pre-visit planning, various types of data and information have been collected in studies. These collected data were very diverse. Hence, these different types of information can be divided into nine categories concerning their application. The different types of information regarding applied techniques are shown in Fig.  7 .

Distribution of different kinds of collected data regarding pre-visit techniques

Determining the main categories of applied techniques regarding medical informatics

Coding of all research studies and extracted themes using thematic analysis leads to discover the main sub-themes in terms of medical informatics. Therefore, all of the employed techniques can be divided into four categories, pre-assessment forms, educational resources, decision aid tools, and reminders as the main themes. The main themes and sub-themed are shown in Fig.  8 . Different aspects of such a model were shaped by mapping the main concepts obtained through this survey. The details of applied techniques in terms of the medical informatics view are described in Table ​ Table2 2 .

The main applied techniques through pre-visit planning in terms of medical informatics

Framework suggestion and IT-based solution

After a qualitative analysis of the results based on predetermined categories, the main ideas can be summarized in a proposed framework as an electronic-based advanced care program. Based on the results, this model is divided into four main parts in terms of time. This model is represented in Fig.  9 . In this model, the main focus is on the patient. The workflow is designed to improve the relationship between physician and patient in the simplest way. It is done by involving the patient in their care, which is one of the main purposes of using pre-visits in studies.

The overall model of pre-visit planning care

In this model, it is assumed that an electronic system is available to manage patient information. To implement a pre-visit-based program, a section is also considered for patient access to his care plan in the proposed model. Based on this model, the patient can pursue the main goals of pre-visit planning through suggested workflow, such as disease management, treatment adherence, receiving the necessary advice and training, and preparing for each visit. To increase the effectiveness of the devised model, it is suggested that the proposed system should have interacted with existing databases and electronic health systems.

Summary of findings

This survey summarized the characteristics of published studies on pre-visit planning and its application in various health domains. To our knowledge, this study represents the first overview of the existing evidence about the different pre-visit planning techniques in clinical practice. Forty-nine articles from ten countries were included in this survey. As mentioned in the results, these techniques can classify into eight categories. Among them, the most widely used methods are related to using electronic pre-office visit checklists and supporting patients by providing them with the necessary information in the form of online and offline educational resources.

Consistent with the present findings, our results showed that applying pre-visit techniques was not restricted to office visits [ 75 ]. So, pre-consultation planning can employ before each patient’s consultation, between the patient’s visits, and during the current visit to facilitate complicated patient care process.

One of the remarkable results of this study is that this approach has been used more in developed countries. It may be because it is easier to take a participatory approach to patient care in developed countries due to a high level of patient literacy.

Results in the context of other researches

Our results showed that most studies have been conducted with the main goal of preparing the patient by involving them in their treatment process. Patient preparedness had the most impact on the patient’s perceptions of his disease and overall patient satisfaction [ 76 ]. Similarly, Ringdal et al. [ 77 ] indicated through their survey that patients were satisfied with their active role as a partner on the healthcare team. Also, this is exactly in line with the main goal of the patient-centered care paradigm regarding the individualized approach to the patient’s treatment [ 78 – 80 ].

However, Geraghty et al. [ 81 ] showed through their study that there is a linear relationship between patient satisfaction and visit length. Unfortunately, long waits are common at outpatient clinics [ 82 ]. Hence, our results illustrated that using a pre-visit assessment tool such as a simple checklist or questionnaire is almost effective to maximize the available time during a consultation for making the best decisions by physicians. Also, it can provide better insight for physicians to better communicate with the patient by knowing the patient’s background during the consultation [ 22 , 33 , 35 , 47 , 54 , 60 , 64 , 67 , 69 , 70 , 83 – 88 ].

Analysis of results revealed that most studies considered the pre-visit assessment tool as an independent solution that was not connected to existing electronic systems. However, in some studies, a comprehensive care plan has been taken. A pre-visit planning program could be linked to a patient’s electronic medical record as used in some reviewed studies. This approach is similar to the motivational interviewing (MI) technique that is applied to improve patient-centeredness in other studies. Motivational interviewing is a technique to help patients address their chief problems and increase their understanding of their participatory role in the treatment process [ 89 ].

Implications for research and practice

Planned and targeted care is one of the main components of the patient-centered care model [ 79 ]. Hence, implementing pre-visit tools within an advanced planned care program might be more effective in moving towards effective patient-centered care. However, pre-visit planning care is a new approach, no framework or conceptual model was introduced according to this subject. Only a planned care model was introduced by the Health Research and Quality Agency as a comprehensive patient-centered medical home (PCMH) approach in which one of its main components is pre-visit planning [ 90 , 91 ]. Hence, our findings are summarized in a conceptual model regarding applying the pre-visit assessment tool in electronic-based planned patient care (Fig. ​ (Fig.9). 9 ). However, the EHR-linked pre-visit type was used only in the nine studies, the suggested model is not devised in a stand-alone model. Nowadays, with the advent of the digital age, applying integrative electronic systems and medical informatics-based solutions are inevitable [ 92 ].

One of the significant gaps that were mentioned in the studies is the unnecessary referrals of patients to outpatient offices [ 93 , 94 ]. These unnecessary visits in the event of pandemics can also lead to the spread of disease [ 95 , 96 ]. In such a framework, avoiding unnecessary referrals was considered to fight the pandemic. Such an approach can be useful to prevent the spread of the COVID-19 disease too.

Limitations

Since this study is the first attempt to review and analyze the published articles regarding pre-visit planning, it encounters some limitations. The results of some studies might be published in the form of reports, letters to the editor, or other types of study. Thus, we might not have considered them based on our exclusion criteria. The results showed that most studies point out pre-visit planning conducted by large institutions and reputable organizations; their data are absurdly confounded by the fact that better-funded institutions probably produce better outcomes. Also, some researchers might put pre-visit into practice but they did not publish their attempts in form of any research article or conference paper. It could cause publication bias. Thus, further researches for specific domains in clinical practices might be done in the future.

Using a systematic review approach leads to get a comprehensive overview of literature conducted in the use of various pre-visit approaches. Our results revealed that the direct outcome of planning a pre-visit care program was enhancing the quality of patient care alongside enhancement patient-provider communication. Improving the patient-physician relationship is a key factor in moving towards a patient-centered care paradigm. The qualitative and thematic analysis of the articles also showed that pre-visit planning has the greatest impact on the relationship between physician and patient. It can account for such a useful tool to move toward patient-centered care. However, such an approach can also be helpful to control pandemic diseases by reducing unnecessary referrals. Thus, the application of pre-visit tools can be considered as one of the key components of designing a patient-centered care system. In this survey, we tried to summarize our findings and our suggestions in a complete patient care framework based on pre-visit planning techniques.

Acknowledgments

We would also like to express our gratitude to Farideh Namazi for their support with us during this research.

Abbreviations

Authors’ contributions.

Conception idea of study: Marjan Ghazisaeeidi, Hamidreza Abtahi, Marsa Gholamzadeh; Acquisition of data: Marjan Ghazisaeeidi, Hamidreza Abtahi, Marsa Gholamzadeh. Analysis and/or interpretation of data: Marsa Gholamzadeh, Marjan Ghazisaeeidi. Drafting the manuscript: Marjan Ghazisaeeidi, Marsa Gholamzadeh. Revising the manuscript critically for important intellectual content: Marjan Ghazisaeeidi, Marsa Gholamzadeh, Hamidreza Abtahi. Approval of the version of the manuscript to be published: Marjan Ghazisaeeidi, Hamidreza Abtahi, Marsa Gholamzadeh. The author(s) read and approved the final manuscript.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Availability of data and materials

Declarations.

The study involves only a review of literature without involving humans and/or animals. The authors have no ethical conflicts to disclose.

Not applicable.

The authors declare that they have no conflicts of interest.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Contributor Information

Marsa Gholamzadeh, Email: ri.ca.smut.izar@hedazmalohg-m .

Hamidreza Abtahi, Email: ri.ca.smut@ihatbarh .

Marjan Ghazisaeeidi, Email: ri.ca.smut@ramizahg .

The need to delegate tasks to other members of the health care team has never been more urgent. Here's how to move toward advanced team-based care.

KEVIN D. HOPKINS, MD, AND CHRISTINE SINSKY, MD

Fam Pract Manag. 2022;29(3):25-31

Author disclosures: no relevant financial relationships.

Team-based care is not just another buzzword. It is a model of care delivery that, when done well, can greatly reduce physicians' administrative burden and elevate clinical staff's role, while improving patient experience, quality, and safety. 1 While many physicians are likely aware of basic team-based care models, advanced team-based care is a comprehensive, integrated model in which physicians perform only the functions they are uniquely trained and qualified to do, and delegate other tasks to capable staff.

This article builds on the awareness of basic team-based care and aids practices in moving to the “next level” by expanding the team and optimizing its performance. The value of effective teamwork in medicine has never been more widely understood than it is today. Many practices face persistent staffing challenges due to intermittent absenteeism, open positions with few qualified applicants, and caregivers who are exhausted or burned out from the grind of the last two pandemic years. Considering the workload for most primary care physicians was unmanageable even pre-COVID, 2 , 3 we presently find ourselves at a crossroads of circumstance and opportunity.

Basic team-based care allows physicians to delegate tasks such as agenda setting, history gathering, and record retrieval to nurses or medical assistants, freeing more time for medical decision making.

Practices can further enhance team-based care by adding behavioral health professionals, clinical pharmacists, care coordinators, or other providers to the care team.

Strategies such as daily huddles, panel management meetings, and synchronized prescription renewals can help teams of any size achieve greater efficiency and better health outcomes.

BASIC TEAM-BASED CARE

Team-based care is designed to enhance efficiency and access, improve quality of care, and increase satisfaction for all involved in medical care (physicians, employees, and patients). 1 , 4 , 5 The physician leads the care team in building relationships with patients, interprets available data, and performs medical decision making, while delegating other tasks.

Engaged, capable, and well-trained clinical staff such as medical assistants (MAs), registered nurses (RNs), and licensed practical nurses (LPNs) are key to successful team-based care. Nurses and MAs can take on many tasks previously performed by physicians, including agenda setting, history gathering, record retrieval, EHR navigation, updating charts, medication review, data entry, order entry, and the bulk of required visit documentation. 1 , 4 , 5 (See “ Tasks physicians may delegate to clinical support staff .”) When the clinical team completes documentation collectively, the quality of the notes can be as good or better than when the physician does it alone. 6

TASKS PHYSICIANS MAY DELEGATE TO CLINICAL SUPPORT STAFF

This is not intended to be an exhaustive list. Nurses and medical assistants may be able to take on more tasks depending on state scope-of-practice regulations.

Performing traditional rooming duties (intake, allergies, medications, vitals, etc.)

Determining chief complaint (drives note template selection)

Agenda setting

Taking preliminary history of present illness/review of systems

Administering pre-ordered vaccines

Considering point-of-care testing

Giving an oral presentation about the patient to the physician

Doing in-room documentation (scribe function)

Implementing plan (pending orders)

Updating problem list

Providing educational resources

Completing forms, letters, etc.

Scheduling follow-up visits

Giving after-visit summary, ensuring understanding

Doing a warm handoff to next team member

Handling charge entry

For team members to take on additional tasks, they need the time and support to do them well. This may require challenging historical staffing ratios. For optimal team-based care, each physician should have 2.0–2.5 full-time equivalents (FTEs) of dedicated clinical support. 7 MAs or nurses are critical to effective team-based care, and they represent the most basic and important building blocks of the team. Expanding the team with additional MAs or nurses allows their skills to be meaningfully used across the spectrum of primary care work. They can serve as embedded patient navigators, allowing practices to avoid introducing additional, more specialized team members, which could inadvertently create more fragmentation in care rather than less. One effective method for starting basic team-based care is to evaluate a practice's existing staff and resources and reimagine who does what. The increased efficiency and revenue associated with team-based care will eventually allow you to add more FTEs as needed. (See “ Team-based care resources .”)

EXPANDING THE TEAM: SIX ROLES TO CONSIDER

When practices can expand the team, it is usually more effective to first add another “generalist,” such as an MA or nurse, rather than a staff member whose role is more limited. Once the generalist clinical support staff has been optimized and tasks delegated, adding other roles may further an advanced team-based care model.

Even if it were possible, we would not advocate adding all of the following positions to a practice because as the number of people and roles on a team grows, at a certain point the work of handing off patients and getting each person up to speed outstrips the benefits. Instead, identify a few key opportunities for team expansion from the following choices, based on your practice's needs.

RN care coordinators were the first additional patient care resource added in my (Dr. Hopkins') practice after we were successful with the two-MA team-based care model. The efficiency we gained from that model allowed us to see enough patients to add care coordinators without adversely affecting the budget. A suggested ratio is one RN care coordinator for every 2–4 physician FTEs. Nurse care coordinators can be invaluable as a shared resource for multiple primary care teams and the main point of contact for patients who need them most. They connect with high-risk patients being discharged from the hospital, assist with transitional care management (TCM) outreach and visits, contact patients who need follow-up after trips to the emergency department, and help manage patients on chronic disease registries. Patients active with our care coordinators have their direct telephone numbers. This has been instrumental in reducing our readmission rate and avoiding unnecessary emergency department utilization. While care coordination work is not directly reimbursable on its own, it is bundled into other billable services such as TCM. Also, organizations participating in value-based payment models are generally paid an upfront “care management fee” to support the cost of care coordination.

Population health navigators could be MAs, LPNs, clinical techs, medical techs, or even clerical team members who can do panel management and help patients navigate the often-intimidating health care system. Navigators can provide access and scheduling assistance to patients for primary care, specialty referrals, and recommended tests or procedures. They can routinely monitor and revise reports such as care-gap registries and shared patient lists, and they can do proactive, targeted outreach for patients who are due for routine follow-up and screenings. If you're unable to hire a designated population health navigator, all of the MAs and nurses within a practice can take on the role on an ad hoc basis, flexing between rooming and desk work as needs ebb and flow.

Clinical pharmacists embedded within a primary care practice can help educate patients to raise health literacy, perform medication instruction to encourage adherence, and partner with physicians to monitor and manage chronic diseases for better patient outcomes. The ratio of pharmacists to physicians will vary from approximately 1:6 to 1:12 based on the social and medical complexity of the patient population. Pharmacists may conduct in-office or virtual visits and be available for real-time in-office or informal consults. In some practices, physician-designed collaborative practice agreements allow pharmacists to start, stop, and adjust medications for chronic conditions, under the physician's direction. 8 These services are billable, whether they occur in office or virtually.

Primary care social workers would ideally be physically present in every practice, but in most cases that may not be practical. However, a centralized group of social workers available to patients and caregivers by telephone or electronic referral can offload some patient assistance tasks. Social workers should be familiar with available local and regional social services, able to assist with medication and transportation issues, and able to support patients and their families with complicated care decisions such as placement in a residential care facility. Primary care social work services are generally not billable, but there are some exceptions. For example, licensed social workers can bill for performing Medicare AWVs (under physician supervision) and for providing certain counseling services.

Behavioral health specialists are another optional resource, ideally co-located within a primary care practice to provide access to traditional behavioral health office visits as well as real-time in-office and informal consults. 9 This team member could be a psychiatrist, psychologist, behavioral health nurse practitioner or physician assistant, counselor, health coach, or social worker. The best optionfor each practice depends on the patients' needs and the availability of each type of behavioral health professional. Depending on their training, these providers can help with mood disorder treatment, substance use disorder treatment, attention-deficit/hyperactivity disorder assessments, sleep disturbance counseling, weight loss and exercise coaching, triaging patients to the appropriate level of care, and even coordinating inpatient psychiatric care. These services are billable, depending on provider credentials and type of care.

Advanced practice RNs (APRNs) and physician assistants (PAs) are becoming increasingly common in primary care practice. APRNs and PAs can increase patient access for scheduled wellness and chronic care visits, as well as acute and walk-in care. In some practices, physicians work in formal pairs with APRNs or PAs, sharing a patient panel, in-basket work, and panel management. An APRN or PA may have dedicated time to manage the inbox, complete administrative tasks, and see patients.

OPTIMIZING THE TEAM: SEVEN STRATEGIES

Adding team members helps, and equally important to practice transformation is workflow innovation and redesign. Goals for clinical outcomes are rising. Regulatory compliance standards are advancing. Demand for telemedicine remains strong. 10 We cannot expect to meet these moving targets without transforming the model in which we deliver care. No physician, practice, or health care system can hire or implement the full scope of the care team described above. Recognizing the current challenges with workforce availability, it may be more feasible to start with making changes that optimize your existing team. The best predictor of a change being successfully implemented is whether it is mutually beneficial to patients, care teams, and systems. 4 Here are some strategies to consider.

Team huddles are used in sports for frequent, brief communication between team members and can serve the same purpose for a clinical team. When and where they take place and who attends may differ by practice, but huddles often take just 5–10 minutes at the beginning of the clinic day. They are most effective when there is a shared purpose and agenda. Which team members are in or out today? What opportunities and challenges might we expect with today's patients? What does each team member need to know, and what do they need to share with the others? Answering these questions ahead of time with a huddle makes the day go more smoothly.

Medicare annual wellness visits (AWV) do not need to be performed by physicians, according to Medicare rules. Physician assistants, nurse practitioners, or clinical nurse specialists may perform them. They may also be performed by other licensed medical professionals (e.g., nurses, health educators, registered dietitians, or nutritionists) working under the direct supervision of a physician. 11 Developing a standard documentation template to ensure the AWV includes all of the required components and having a nurse, MA, or other staff member complete the template frees physicians to provide more undivided attention to their patients. While some practices bring the patient in for an additional appointment with staff to complete the AWV, a “co-visit” model with staff and physician can also be effective. Under this model, nursing staff completes the required data collection, documentation, and preventive-care scheduling during the rooming process of a physician visit. This reduces redundancy and patient inconvenience. Using a registry to identify eligible patients who are not scheduled for future AWVs provides an opportunity for patients who may not have been active with the practice recently to reestablish care and could improve patient retention.

Population health management training is a process of educating and empowering each team member to take care of the whole patient. When everyone on the team understands the importance and impact of specific interventions on overall patient health, they are more likely to be active participants in this valuable work. Clinical decision-making should remain with the team's physicians, while others on the care team work through patient lists, reach out to those who are overdue for care, schedule follow-ups, and confirm patient status and record accuracy.

Panel management meetings are longer, more specialized huddles that bring the care team together to collaboratively review certain groups of patients and develop action steps for each patient. These meetings might be weekly, monthly, or on a different cadence, and they might include different team members depending on the type of patients being reviewed. Teams can use data from the EHR or other sources to select groups of patients to focus on at each meeting — e.g., patients with frequent emergency department visits, patients who haven't been seen in the previous 36 months, patients enrolled in care coordination, or patients who have a high risk score. Teams can then discuss how to improve the health of these patients, leveraging all resources at their disposal, and assign responsibility for putting the plan into action. This type of panel management is valuable in any payment model, but particularly in a risk-based or capitated model.

Pre-visit planning is a strategy to help scheduled appointments go smoothly and productively. It entails creating protocols for basic or in-depth tasks that can be shared across a care team to prep patients and practices for the visit. Pre-visit planning begins with using the end of each visit to prepare for the patient's next visit. The physician communicates the timing of the next appointment and outlines any tests that will be needed. For patients with a chronic disease like diabetes or hypertension, staff can ensure proper lab tests are ordered and results are available at the next visit.

Some primary care teams and health systems have incorporated point-of-care lab tests into pre-visit planning, an arrangement popular with patients. 12 Others have implemented evidence-based pre-visit protocols for patients with certain chronic diseases to monitor medications and to ensure patients are receiving screening/preventive care on schedule. Technology can increasingly automate this process and individualize it for each patient.

Pre-visit planning also can include identifying care gaps the day before or the morning of an appointment so that staff are prepared to give needed immunizations or schedule any overdue screenings. For more complex patients, staff may conduct a pre-visit phone call to identify any new issues patients may want to discuss. This can help visit efficiency and allows for a medication review while patients are at home and able to look at their medication bottles.

The final step in pre-visit planning is a very brief (1–2 minute) mini-huddle between the nurse/MA and the physician just before the physician greets the patient. This allows staff members to share key social or medical issues they identified during rooming to help the physician focus the visit.

Synchronized prescription renewal is a process improvement for renewing all chronic medication prescriptions for a patient at the same time, once a year, with slightly more than a year's supply of refills. Ideally, each prescription is written for a 90-day supply with four refills (providing 15 months of medication authorization). This improves medication adherence and can save a typical primary care practice hundreds of hours of work annually.

Patient portal message delegation is essential to helping patients, physicians, and care teams stay connected. Without the support of the care team, portal messages can become just one more task that consumes physicians' limited time.

Patient portals store messages in the EHR as an encounter type, usually with the same functionality as other encounter types such as telephone or in-person visits. This allows the care team to respond to the patient, place orders, and update the chart within the same screen.

The volume of patient portal messages for the typical practice has increased steadily over the past decade, and particularly dramatically during the COVID-19 pandemic. Data from one large EHR vendor showed a 157% increase in incoming patient messages during the pandemic's first year, with each message requiring physicians to spend an average of 2.32 additional minutes in the EHR. 13 Physicians cannot absorb all of that time. 14 All incoming patient messages should first be reviewed by members of the care team, who handle those that they can adequately address. The small number of messages that require the physician's attention can be prepped to the extent possible, then routed to the physician for review and action.

PUTTING IT ALL TOGETHER

A 2014 article in Annals of Family Medicine described the “Quadruple Aim” of medicine, taking the “Triple Aim” (better patient outcomes, lower cost, and better patient experience) and adding a fourth, equally important priority: care team well-being. 15 Supporting wellness among health care workers is a critical tenet of significant and sustainable care model innovation and improvement. Caregivers who are well physically, emotionally, and spiritually will naturally provide better care and experiences for the patients they treat than caregivers who are unhealthy, exhausted, or burned out. 16

Over the past decade, more individuals, health systems, and advocacy organizations have embraced taking care of the care team as essential to delivering the highest quality patient care. The team-based protocols outlined above can help your practice increase caregiver wellness and decrease burnout, as well as improve patient outcomes. Starting, and then advancing, a team-based care model can be a win for everyone.

TEAM-BASED CARE RESOURCES

AMA STEPS Forward:

General team-based care

Expanded rooming and discharge protocols

Team documentation

Telemedicine and team-based care

Clinical pharmacists

American College of Clinical Pharmacy, Comprehensive medication management in primary care study

AMA STEPS Forward, Embedding pharmacists into the practice

Behavioral health professionals

FPM editorial, Integrating behavioral health into primary care

FPM article, Bringing behavioral health into your practice through a psychiatric collaborative care program

AMA STEPS Forward, Behavioral health integration into primary care

Team huddles:

FPM article, Huddles: improve office efficiency in mere minutes

AMA STEPS Forward, Daily team huddles

Medicare annual wellness visits

AAFP, Annual wellness visit

AMA STEPS Forward, Streamline workflow to perform a thorough AWV

Population health management training

FPM article, Put your clinical data to work with a registry

AMA STEPS Forward, Patient care registries

Panel management meetings

University of Washington School of Medicine, Panel management meeting workflow for panel managers

FPM article, The right-sized patient panel: a practical way to make adjustments for acuity and complexity

AMA STEPS Forward, Panel management

Pre-visit planning

FPM article, Putting pre-visit planning into practice

AMA STEPS Forward, Pre-visit planning

AMA STEPS Forward, Pre-visit laboratory testing

Synchronized prescription renewal

FPM article, A streamlined approach to prescription management

AMA STEPS Forward, Annual prescription renewal

Patient portal message delegation

FPM article, Practical ways to manage your EHR inbox

AMA STEPS Forward, Patient portal optimization

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Sinsky CA, Jerzak JT, Hopkins KD. Telemedicine and team-based care: the perils and the promise. Mayo Clin Proc . 2021;96(2):429-437.

Code of Federal Regulations; 410.15. Annual wellness visits providing personalized prevention plan services: conditions for and limitations on coverage. Last updated March 4, 2022. Accessed March 9, 2022. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-410/subpart-B/section-410.15

Crocker B, Lewandrowski E, Lewandrowski N, Gregory K, Lewandrowski K. Patient satisfaction with point-of-care laboratory testing: report of a quality improvement program in an ambulatory practice of an academic medical center. Clin Chem Acta . 2013;424:8-11.

Holmgren AJ, Downing NL, Tang M, Sharp C, Longhurst C, Huckman RS. Assessing the impact of the COVID-19 pandemic on clinician ambulatory electronic health record use. J Am Med Inform Assoc . 2022;29(3):453-460.

Adler-Milstein J, Zhao W, Willard-Grace R, Knox M, Grumbach K. Electronic health records and burnout: time spent on the electronic health record after hours and message volume associated with exhaustion but not with cynicism among primary care clinicians. J Am Med Inform Assoc . 2020;27(4):531-538.

Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med . 2014;12(6):573-576.

Trockel MT, Menon NK, Rowe SG, et al.; Assessment of physician sleep and wellness, burnout, and clinically significant medical errors. JAMA Netw Open . 2020;3(12):e2028111.

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