Planning Care in Any Microsystem

Effective microsystems are designed with the patient, or recipient, in mind (Nelson et al., 2002). Today many of the most progressive microsystems design care or improve their existing design of care not only with the patient in mind but also with patients and families serving as full members of the team. The worksheets in the Appendix "Primary Care Practice Patient Viewpoint Survey" (Figure A.4) and "Through the Eyes of Your Patients" (Figure A.5) are helpful tools to gain deeper insight into the patient and family experience to enable "just right" improvements based on direct patient feedback.

Microsystem staff must make sure that as they develop more efficient services, they focus on the provision of planned care. Attributes of planned care and planned services designed to meet individual patient needs are summarized in Figure 7.2 and Table 7.2. By incorporating components of the planned care model into its practice, a clinical microsystem promotes productive interactions between patients and clinical staff. (Additional information about the planned [chronic] care model and practice assessment forms can be found at


People with health care needs


High risk

Core Flow

High risk



Patient Self-management



People with health care needs met

Functional Biological K+iĆ  Satisfaction

Planned Care Processes

MD visit


Web care

Group visits

Nurse visits & follow-up

Telephone care and follow-up

Reminder systems

Self-care enhancers

Protocols guidelines

Home assessment

PRN specialist consults

Peer counselors

Community resource links

Supporting Processes

Appt. system

Answering phones


Reporting diagnostic test results

Prescription renewals

Making referrals

Pre-authorization for services

Billing & coding

Info systems & data

Physical space

Recruiting, hiring, growing staff



Palliative ++


Chronic ++


Note: PCP = primary care physician; PRN = as needed.


Element of the Planned Care Model


Health Care Organization

Community Resources and Policies

Self-management Support

Delivery System Design

The business plan includes measurable goals for system improvement.

Senior leaders visibly support system improvement. Effective improvement strategies aim for comprehensive system change.

Open and systematic handling of errors is encouraged, with a view to improving quality of care. Provider incentives and avoidance of disincentives encourage better care.

Developing staff and integrating them into the culture is an organizational priority.

Leadership develops relationships that facilitate care coordination.

Effective programs are identified and patients are encouraged to participate.

Partnerships are formed with community organizations to support or develop interventions that meet patient needs.

Each patient's central role in managing his or her illness is emphasized.

Patient self-management knowledge, behaviors, confidence, and barriers are assessed. Effective behavioral change interventions and ongoing support with peers or professionals are provided. Culturally competent and linguistically appropriate approaches are used in patient interactions. The organization ensures collaborative care planning and problem solving by the team.

Team roles are defined, and tasks are delegated among team members.

Staff are employed to the extent of their scope of practice. Demand is measured, and master schedules are developed that match capacity and demand. Patients have access to care when they want it. Complex patients receive clinical case management services; this includes communicating with other settings where these patients are receiving care. Planned visits are used to support evidence-based care. Patients are assured of regular follow-up by the primary care team.

Interpretive services are provided for non-English speakers and low-literacy patients.

TABLE 7.2. (Continued)

Element of the Planned Care Model


Decision Support

Clinical Information System (IS)

Evidence-based guidelines are embedded in daily clinical practice.

Linkages are established between primary care and specialty providers in order to facilitate care coordination.

Specialist expertise is incorporated into primary care. Proven provider education modalities are used to support behavioral change.

Patients are informed about guidelines pertinent to their care.

Staff use standing or standard orders.

IS includes a registry function that summarizes clinically useful and timely information on all patients with particular characteristics.

IS provides timely reminders and feedback for providers and patients and provides protection against errors. Registry can identify relevant patient subgroups for proactive care.

Registry facilitates individual patient care planning. IS facilitates timely sharing of information between care settings.

Many clinical groups currently do not get the right information to the right place, do not match staff roles to the work, and do not build efficiency and effectiveness into practice flow. Furthermore, for a significant number of issues, clinicians do not know what matters to their patients (Braddock, Edwards, Hasenberg, Laidley, & Levinson, 1999; Magari, Hamel, & Wasson, 1998; Nelson et al., 1983). In the absence of a deep understanding of what matters to a patient, interactions are unlikely to be productive.

It is imperative that clinical microsystems plan services that match the needs of their patients. Because a patient with a chronic condition must manage it for many years, the microsystems must provide sufficient patient self-management support (as exemplified in Table 7.2). The microsystem must provide care for the illness and guidance so that the patient can live as normal a life as possible and mitigate the psychosocial impact of the condition.

The 'Assessment of Care for Chronic Conditions" (Figure A.7) is a helpful tool in the appendix to begin to learn the patient perspective about chronic disease care to support improvement and redesign the roles and process to better meet patient needs.

As a general rule, the less ready the patient is for self-management, the more resources the microsystem needs to devote to this process. Resources are most effective when they seamlessly support self-management during assessment, management, and follow-up. As previously noted, the microsystem's staff resources go well beyond the number of available physicians.

In many clinical settings patient and information flows follow the pattern illustrated in Figure 7.2; for almost every clinical need of a patient, a microsystem must ask itself who and what will meet that need and when, where, and how will that need be met.

For example, when an inquisitive microsystem is concerned about the best way to manage a patient who has pain, it confronts a series of questions about assessment and the planning of care. For example:

1. Who will identify the patient with pain? Will this be done by interview or by a self-assessment tool?

2. With what measure will the pain problem be identified? Will the measure be paper based or electronic? Will it assess other problems that matter to the patient at the same time?

3. When will the pain be identified? Will it be identified during or before an office visit?

After the microsystem has developed answers to these questions, it can conduct a few tests with a few patients to see which answers will lead to the most efficient and effective processes. The same question and test process is used to discover the best approaches for the management of patient needs. Finally, the microsystem has to consider follow-up and monitoring: who, what, when, where, and how? Again, the preliminary answers to these questions need to be tested with a few patients.

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