1
Conducting a Continuing
Care Clinic
Handbook for Practice Teams
March 5, 2001
Center for Health Studies
Group Health Cooperative
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Table of Contents
Overview
FastFacts
Designing a CCC
Clinical Roles
Team Meetings
Scheduling Checklist Template
Clinical Priorities for Diabetes and the Frail Elderly
Timeline
Scheduling Templates:
AM clinic, one MD
AM clinic, two MDs
PM clinic, one MD
Sample letter to patient
Older Adult Worksheet
Geriatrics 101
2
3
4
6
7
8
9
10
11
12
13
14
15
16
This guide is intended to assist practice teams in using the continuing care clinic model
for managing patients with a selected diagnosis or condition, such as diabetes or frail
elderly. The guide is considered a template which can be modified to fit the needs of
individual teams.
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THE CONTINUING CARE CLINIC VISIT and YOUR PRACTICE
A Tool for Implementing Population-based Managed Care for Your Patients with Selected Medical
Conditions
A Primary Care Tool to Assist with the Care of Patients with Chronic Conditions:
One method for caring for patients with chronic conditions is a regularly scheduled "Continuing
Care Clinic." The Clinic brings groups of patients to the primary care facility at one time.
Patients receive the necessary routine primary care through one-on-one time with their physician
and other team members and education in a group setting. In essence, the clinic visit allows
patients to experience one-stop chronic illness care during a half-day visit. As an option, the
primary care physician may want to consider having joint visits with the appropriate specialty
care physician.
Elements of Care Incorporated in the Continuing Care Clinic:
1. Routine clinical/preventive care:
for example, for patients with diabetes; eye and foot care, psycho-social assessment,
specialty referrals, nutrition counseling, labs and lifestyle assessments
2. Drug management: simplicity, avoidance of adverse effects, cost, adherence.
3. Periodic health status assessments.
4. Patient education and coaching integrated into care.
5. Support and assistance with behavioral and life style changes.
6. Contact with primary care team enhanced.
Key Objectives for the Continuing Care Clinic:
1. Prevent or minimize complications for patients which may lead to excess disability.
2. Proactively manage the care of a specific populations, especially coordination of preventive
services, through the use of priority worksheets and/or computerized patient registry and
information system (such as is currently available for heart care and diabetes).
3. Systematic inclusion of all patients in a population to ensure that necessary routine care is
accomplished on an automatic basis in a supportive group environment.
4. Tests and evaluations are done based on evidence of efficacy (when available) or on
established standards of care.
5. The care delivery team actively defines roles to deliver the needed components of care.
6. Patients and physicians remain partners in determining the plan of care.
7. Outcome-based evaluation processes are built into system.
Key Outcomes Achieved via Regularly Scheduled Continuing Care Clinics:
1. Overall patient health status (for example, reduce glycosolated hemoglobins, foot ulcers,
blood pressure, functional status).
2. Consumer satisfaction with health care delivery (regularly scheduled one stop care).
3. Provider satisfaction with chronic illness care and patient tracking.
4. Reduction in unnecessary utilization (ER visits, Hospitalizations, Urgent Care Visits).
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Continuing Care Clinic
Fast Facts for Provider Teams
What work is required?

Review your patient panel to determine focus of continuing care clinic and to exclude
those who are inappropriate for the visit.
How many patients do I need to “see”?

Each half day Continuing Care Clinic has appointment slots for 8 or more patients (a
cohort.) There is a one hour block (while the patients are in the group meeting) when
the physician may perform other duties. The nurse may be involved in the group
meeting.
How are patients chosen?
 Patients are selected from among those in your panel: Each practice may determine
the focus of the continuing care clinic Some examples include: diabetes, cardiac
disease, frail elderly, multiple sclerosis.
 The clinic is described to patients, who may choose not to participate.
What else will I need to do?
 Each team will need to meet regularly for planning care to the continuing care clinic
group.
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Suggested Protocols for Designing A Continuing Care Clinic to Fit Your Practice
A Planning Guide
Patient Scheduling Considerations:
1. Review your patient panel and determine the focus of the continuing care clinic.
2. Determine the Continuing Care clinic (CCC) schedule needed to see all your patients at a
predetermined interval during the year. You will need to know:
# of patients with the condition of interest
# of CCC visits each ear
# of patients per CCC cohort (typically 12, allowing for some absences at each visit)
a) Divide the # of patients by the # in the cohort
Ex: 120 patients with diabetes = 10 cohorts
12
b) Determine the visit interval and assign cohorts to a schedule
Ex: Every 3 months
Jan – May – Sept = 2 cohorts (1 starting in Jan, 1 in May)
Feb – June – Oct = 3 cohorts (1 starting each month)
Mar – July – Nov = 3 cohorts (1 starting each month)
April – Aug – Dec = 2 cohorts (1 starting in Apr, 1 in Aug)
c) Thirty ½-days will be needed:
Jan: 2 ½-days
Feb: 3 ½-days
Mar: 3
Apr: 2
May: 2
June: 3
July: 3
Aug: 2
Sep: 2
Oct: 3
Nov: 3
Dec: 2
3. Once the CCC schedule is determined, schedule the half-days for the next year. Be sure to
block off actual time slots for MD on visit day in your appointment system. Schedule,
RN, pharmacist or other team members.
Assign cohorts of approximately 12 patients to each schedule.
4. At routine intervals about 1 month before their first scheduled CCC, mail a letter of
introduction about the CCC to the selected patients to determine their interest in
participation.
5. Two weeks after sending the letter, and prior to the first CCC visit, call patients and confirm
their attendance.
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6. Review patients' medical records and determine clinical priorities.
7. Using the scheduling template provided, lay out each patient schedule of care for the visit:
Be sure the patient is not in two places at once or that the same provider is seeing two
patients at once!
8. Complete individual patient schedules and mail to patient along with confirmation letter
(sample provided); be sure patient receives confirmation of CCC visit two weeks ahead of
the visit day so that they can visit the lab to have requested blood work done as needed.
9. Order lab work and send lab requisitions to appropriate lab facility as needed.
10. Call patients 1 week prior to visit day to remind about schedules and lab work.
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Clinical Facility Preparation Considerations:
1. Arrange telephone and visit coverage and plan for RN seeing patients during CCC visits.
2. Arrange for Medical Assistant during the CCC.
3. Schedule room large enough to handle all patients during patient education class.
4. If appropriate, arrange with registration personnel to have patients register once for all care
services they are to receiving so patient is only charged one copay for all scheduled visits.
5. Arrange for three exam rooms so patients can be visiting with pharmacist, RN, and MD at
same time.
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Continuing Care Clinics Clinical Roles
Clinical Roles: (revised according to team configuration)
Clinic Coordinator:
Assist with communications at facility (clinical staff, business office)
Reserve rooms as needed
Assist with identification of dates for team meetings and clinics
Office assistant:
Identify tentative dates for clinic with all staff involved
Hold appts in schedule when clinic dates are determined.
Assure that appointments for individuals attending the clinic are
entered into appointment system.
Schedule clinics with patients
Reserve conference room
Send notification to patients
Distribute schedules to team members
Call patients to remind of clinic 1-2 days before scheduled clinic
MA or LPN:
Greet and escort/direct patients. Be responsible for managing
patient flow.
Collect and record vital signs and other assessments as needed
Assist with group visit logistics.
RN:
Pre Clinic:
Review charts and notify assistant of any labs needed
Establish group focus (with social worker if available)
Participate in arranging for guest speakers when content requires.
At Clinic:
Meet with patients one-on-one focusing on self care behavior changes
Lead group (in some settings)
Btwn clinics: Identify common information needs of patients for inclusion in group.
Telephone follow-up with patients for behavior change support.
MD:.
At Clinic:
Formulate, communicate and oversee plan of care for patients.
MSW:
Pre clinic:
At Clinic
Meet with RN to plan for group sessions.
Actively facilitate group session, individual visits as needed.
Pharmacist At Clinic:
or
other specialist
involvement:
Review all patients medications with the patient at least annually.
ID drug related problems and recommend medication changes to MD.
Participate in group sessions when content is relevant.
Track medication related intervention outcomes, costs and savings.
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Continuing Care Clinics
Each team is encouraged to hold routine meetings. The following topics may be useful.
First Team Meeting
I
(2 min) Review/Modify Agenda
Goal: Identify all issues to be covered at meeting
II
(35 min) Planning for the Continuing Care Clinics
Goals: 1) Review purposes/goals of clinic
2) Make necessary decisions to implement first clinic
A. Review purposes of clinics and goals for first clinic, including
schedule of clinical priorities to be addressed during the year (5
min)
B. Determine number of cohorts. (Review lists of participants)
C. Verify dates and hours of first clinics;
(Are all team members (MSW, RN, MD available ?)
(Choose appointment schedule - appt lengths)
D. Identify patients for clinics.
E. Determine if/when lab work needed (glycoHb, lipids, BUN,
creat.)
G. Identify practice contact person
H. Verify date for next team meeting
III
(3 min) Meeting evaluation
Goal: Determine what worked, what didn’t for future meetings
Second Team Meeting:
“Walk through” of first clinic - paperwork, team communication, group session and
follow-up planning.
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Scheduling Checklist Template
Steps
I.D. tent. dates for clinic
Hold on appt. book
Holds on other schedules
OK date with:
MD
RN
Pharm
MSW if avail
Nutrition prn
Reserve group room
Call Patients
Identify lab for each pt,
notify pt.
Fill out lab slips and
provide to Office Asst.
Draft Schedule
Confirm coverage
Establish group focus
Final schedule to:
team (3 copies),
Clin Coord, pharmacy,
(MSW, nutrition)
Mail pt letter
Phone patients to remind
Chart Review before
clinic (RN/MD)
Debrief following clinic
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Clinic Coord Off. Asst.
X
X
X
RN
SW
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
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Continuing Care Clinics
Sample Clinical Priorities
For Diabetes and Frail Elderly
Clinical priorities should be derived from evidence-based guidelines
which include treatment protocols.
Diabetes:
1) Reduction of macrovascular complications (smoking
cessation, BP control, daily ASA, Lipids)
2) Reduction of microvascular complications (foot,
kidney, eyes)
3) Function/Affect (functional status, depression and
incontinence)
4) Self Management (diet, exercise, etc.)
5) Glucose control
Routine Assessments:
self management behaviors
feet
glycohemoglobin
lipids
microalbuminuria
Elderly:
1) Medication management (four or fewer meds; avoid
sedatives)
2) Reduce risk of falls (mobility/fitness/exercise, alcohol
use, home safety)
3) Function/Affect (physical function, depression and
incontinence)
4) Chronic Illness Management
5) Planning for the Future (Durable POA, Advance
Directive)
Routine Assessments:
functional status
depression
incontinence
self management behaviors
medications
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falls
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Sample Schedule
First Clinic Visit (baseline)
Clinic: Pharmacy Brown Bag, Review status, identify priorities for change
Develop and document a plan for care
Group: Introduction to clinic and one another; activation, identify issues for future
sessions
Interim telephone follow up: behavior change support and clinical status
Second Clinic Visit (3-4 months)
Clinic: Follow Up on Plans
Foot Assessments for diabetics; Nutrition visits for selected patients
Pharmacy follow up on selected patients
Group: Cardiovascular risk reduction (Exercise) or
Nutrition, or topic chosen by group on first visit
Interim telephone follow up: behavior change support and clinical status
Third Clinic Visit (8-9 months)
Clinic: review health maintenance needs, reevaluate self management, follow-up
Group: Varies depending on cohort needs and desires (Nutrition, Exercise, Home
Safety, Depression, Fatigue, Adv. Directives, Community Resources)
Interim telephone follow up: behavior change support and clinical status
Fourth Clinic Visit (12 months)
Clinic: Annual assessments and self care/educational needs
Group: Varies
Interim telephone follow up: behavior change support and clinical status
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Sample Patient Letter
Dear _____________,
In order to better care for patients with X (condition,) we are beginning a
Continuing Care Clinic (CCC.) Patients who participate in the CCC will be scheduled to
come to the clinic (three) times each year. At each visit, you will see the pharmacist,
doctor, and nurse, and have an opportunity to participate in an educational and supportive
group. These planned visits will allow us to concentrate on the care of X.
You are invited to the first CCC (next month.) _________________, RN will be
calling you in the next few weeks to describe the CCC in more detail and schedule your
visit. You may contact (him/her) at (phone #) if you prefer.
Your participation is voluntary, but we are confident that you will benefit from the
CCC. We look forward to talking with you about the CCC.
Sincerely,
______________, MD
for the health care team at _______ Clinic
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Continuing Care Clinic
“Working together to maintain your health”
_______________________________________________
Your CCC visit is scheduled for*:__________________________
Please check-in at: ___________
Group session:___________
Pharmacist visit:
_________
MD visit:
_________
RN visit:
_________
Other:___________________
Your spouse or other family member or friend is welcome to attend
the clinic with you. We look forward to seeing you.
If you find a lab slip enclosed, please have lab work done
during the week prior to your clinic appointment. This will
ensure that results are available for review during your visit.
THIS IS AN APPOINTMENT. PLEASE CALL AND LET
US KNOW IF YOU WILL NOT BE ABLE TO ATTEND
(CLINIC) - APPOINTMENT #: (***)
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One Provider, Morning Clinic, 15 minute visits
Check In
Pharmacy
MD
RN
Group
8:40
8:45-9:00
9:00-9:15
9:15-9:30
10:30-11:15
8:55
9:00-9:15
9:15-9:30
9:30-9:45
10:30-11:15
9:10
9:15-9:30
9:30-9:45
9:45-10:00
10:30-11:15
9:25
9:30-9:45
9:45-10:00
10:00-10:15
10:30-11:15
9:40
9:45-10:00
10:00-10:15
11:30-11:45
10:30-11:15
Patient #6
9:55
10:00-10:15
11:30-11:45
11:45-12:00
10:30-11:15
Patient #7
9:55
10:15-10:30
11:45-12:00
12:00-12:15
10:30-11:15
Patient #8
10:25
11:30(or no visit)
12:00-12:15
12:15-12:30
10:30-11:15
Patient #1
Patient #2
Patient #3
Patient #4
Patient #5
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Continuing Care Clinics
Schedule Template - Dual (two concurrent) AM clinics
MD A
Name
Patient #1
Check in
Pharmacy
MD Visit
RN Visit
Group Session
8:40
8:45-9:00
9:00-9:15
9:15-9:30
10:30-11:15
8:55
9:00-9:15
9:15-9:30
9:30-9:45
10:30-11:15
9:10
9:15-9:30
9:30-9:45
9:45-10:00
10:30-11:15
9:25
9:30-9:45
9:45-10:00
10:00-10:15
10:30-11:15
9:40
9:45-10:00
10:00-10:15
11:30-11:45
10:30-11:15
10:25
no pharmacy
11:30-11:45
11:45-12:00
10:30-11:15
10:25
no pharmacy
11:45-12:00
12:00-12:15
10:30-11:15
Check in
Pharmacy
MD Visit
RN Visit
Group Session
9:25
no pharmacy
9:30-9:45
9:45-10:00
10:30-11:15
9:40
no pharmacy
9:45-10:00
10:00-10:15
10:30-11:15
10:05
10:10-10:25
11:30-11:45
11:45-12:00
10:30-11:15
10:25
11:30-11:45
11:45-12:00
12:00-12:15
10:30-11:15
10:25
11:45-12:00
12:00-12:15
12:15-12:30
10:30-11:15
10:25
12:00-12:15
12:15-12:30
12:30-12:45
10:30-11:15
10:25
12:15-12:30
12:30-12:45
12:45-1:00
10:30-11:15
Patient #2
Patient #3
Patient #4
Patient #5
Patient #6
Patient #7
MD B
Name
Patient #1
Patient #2
Patient #3
Patient #4
Patient #5
Patient #6
Patient #7
t:inst/rwj/ccc/handbook/sched2am.doc
Chronic Care Clinics
Schedule Template - PM clinic
Name
Patient #1
Check in
Pharmacy
MD Visit
RN Visit
Group Session
1:25
1:30-1:45
1:45-2:00
2:00-2:15
3:30-4:15
1:40
1:45-2:00
2:00-2:15
2:15-2:30
3:30-4:15
1:55
2:00-2:15
2:15-2:30
2:30-2:45
3:30-4:15
2:10
2:15-2:30
2:30-2:45
2:45-3:00
3:30-4:15
2:25
2:30-2:45
2:45-3:00
3:00-3:15
3:30-4:15
2:40
2:45-3:00
3:00-3:15
4:30-4:45
3:30-4:15
2:55
3:00-3:15
4:30-4:45
4:45-5:00
3:30-4:15
Patient #2
Patient #3
Patient #4
Patient #5
Patient #6
Patient #7
t:inst/rwj/handbook/schedpm.doc 8/1/2016