1. Putting all your skills together into an efficient visit Creating value for the patient

2. 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

3. 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

4. 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)

5. 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!

6. 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

7. Covering priorities creates value Prioritize CCs while negotiating Today’s Agenda Limiting number of priorities to the “size of your box” 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!

8. 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!

9. 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

10. 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?

11. 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?

12. 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!)?

13. 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?”