Putting all your skills together into an efficient visit
Creating value for the patient
Learning Objectives
 Knowledge of “micro-skills” does not always translate
into effective use of them
 Patients 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 track
 Practice scenarios
 Focus for chart reviews for next month
FP is the specialty of Synthesis
 Subspecialists are experts at analysis
 FPs have consistently delivered better value because
we emphasize synthesis
 American culture celebrates analysis
 Value 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 fault
when 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 better
 Planning care over time
 Sizing the visit(s) to maximize benefit and payment(s)
Teamwork
 Everyone needs to know the “sizes” of E&M services
 Everyone needs to know when & how visits can be
extended or truncated
 How the scheduler can help
 How the receptionist can help
 How the nurse can help
 What the provider must do to make it happen!
Keeping the patient “on task”
 Confirm the agenda after initial greetings
 Conditional acceptance of problematic agendas
 Complete histories one CC at a time in priority order
 Truncate history taking 1/3 of way through visit
 Do 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 value
 Prioritize CCs while negotiating Today’s Agenda
 Limiting number of priorities to the “size of your box”
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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 insurers
 requires patient-centered explanation and
 specialist-centered political skills!
Planning care-over-time
 Every patient leaves with a plan for follow-up
 Complex care may have plan for multiple services
 Priorities 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 this
 They 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 all
 One-size-fits-all appointments does not mean
one-size-fits-all services!
 “Huddle” with your nurse before set to “size” appointments
 Nurse frames type of visit when asking for patient’s agenda
 Provider gives “sign posts”
 when changing frames
 when 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 1
 Patient 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 2
 Patient 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 3
 25 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 month
 Is 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?”