Publications

WorkflowTemplates, flow sheets and mapping aids

  • Workflow

    Team Member Roles in Planned Care

    See how one LEAP site organizes the entire care team around delivering proactive, population-based primary care. This document shows which team members are responsible for each task involved in planned care, divided into 3 domains: pre-visit, visit, and between visit. Everyone has important roles: the provider, team RN, MA, receptionist, planned care coordinator, community resource specialist, referral coordinator, pharmacist, and complex care manager. 

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    Attribution: 
    Cambridge Health Alliance - Union Square Family Health
  • Workflow

    Pre-visit screening EMR template

    See the EMR template developed by one LEAP site to facilitate planned care. The Pre-visit screening template populates with date of last service and current status for immunizations, HIV, LDL, A1c, PSA, pap, mammogram, glaucoma, advanced directives, and more.

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    Attribution: 
    Southeast Texas Medical Associates
  • Workflow

    Care Team Huddle roles and responsibilities

    Learn from the protocol used to guide team huddles at one LEAP site. Notice the various pieces of information prepared in advance by each team member, so that the huddle is efficient and effective to coordinate care for patients during each shift.

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    Attribution: 
    West County Health Centers, Inc.

Role featuresJob descriptions, career ladders and other HR materials

  • Role features

    Description of the MA/LVN role

    Learn about the MA/LVN role in planned care at one LEAP site. The MA/LVN spends 15-30 minutes with patients to review preventive and chronic illness care needs, before the provider even enters the room.

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    Attribution: 
    Southeast Texas Medical Associates
  • Role features

    "Share the Care" Assessment of Team Roles and Tasks

    This is an example of a planning tool, to assess who is currently doing what tasks in your practice and then who should be doing each task, based on how we learned that LEAP sites define clear roles and responsibilities. Task distribution will vary from practice to practice, but the tool is in the discussion about roles that this worksheet can stimulate. Your practice may be able to redestribute tasks in a way that better fits your workforce and patient needs.

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  • Role features

    Care Manager Role in Diabetes Management: Follow-Up

    See the role played by the RN Care Manager at one LEAP site, in following up on diabetic patients. This table describes the important follow-up to provide for diabetic patients in between provider visits, both in-person and by phone. For example, for patients with high risk or poor control (A1c of 9 or higher), the Care Manager follows up 2 weeks after a provider visit, followed by a series of other follow-ups for at least 4 months.

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    Attribution: 
    Daughters of Charity Services of New Orleans

ToolkitsImplementation guides and other documents with extensive resources included

  • Toolkits

    Resources for Effective Huddles

    Explore resources developed by one LEAP site to help care teams run effective huddles focused on making the most of patient care visits. This document contains: a description of team huddles (and how they differ from other team meetings), strategies and a checklist for good huddles, and a self-assessment.

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    Attribution: 
    Cambridge Health Alliance - Union Square Family Health

Clinical protocolStanding orders, risk stratification forms and hospital transition protocols

  • Clinical protocol

    Flu Vaccine Standing Orders

    See an example of standing orders to administer the flu vaccine, developed by one LEAP site. The standing orders include a statement of purpose, guidelines, and recommendations by age of patient. As noted in the standing order, the listed vaccines can be administered by any appropriate staff members by following the protocol, without need for a physician evaluation or order.

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    Attribution: 
    Dartmouth-Hitchcock Keene
  • Clinical protocol

    Standing Orders for clinic staff

    See an example of standing orders from one LEAP site, which allow team members to order labs and perform some services for some patients automatically without provider pre-approval. This helps provide high quality care for patients, particularly those with diabetes, hypertension, COPD, asthma, and depression. Furthermore, team members can perform labs at community health fairs based on these standing orders.

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    Attribution: 
    High Plains Community Health Center
  • Clinical protocol

    Standing Orders for non-physician personnel

    See an example of standing orders from one LEAP site, which allow team members to refill medications, draw labs, administer vaccines, and perform other services without direct order from a physician.

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    Attribution: 
    Miramont Family Medicine
  • Clinical protocol

    Diabetes Protocol for Medical Assistants

    See an example of standing orders from one LEAP site, where the Care Team MA can perform tasks related to diabetes care without first consulting a provider.

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    Attribution: 
    West County Health Centers, Inc.

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