What is the challenge?

Older research showed that Americans received only half of the services that evidence indicates they need. It has improved some with time, but national quality data still reveal major gaps in the quality of ambulatory care, even for patients who regularly use the health care system.

What needs to change?

The Institute of Medicine in its pivotal report, Crossing the Quality Chasm, attributes the mediocre quality of U.S. health care to the medical care system’s reactive nature. Encounters tend to be devoted to acute problems leaving little time to meet patients’ preventive or chronic illness care needs. If these needs are identified prior to the encounter, a well-organized practice team can ensure that patients get the services they need. To do so, practices need ready access to information on what services are due, clear assignment of tasks to specific practice team members, and pre-visit meetings to plan care. 

What do we gain by making these changes?

Practices that use patient data to identify needs, and organize the team to meet those needs see noticeable improvement in their quality metrics.

  1. Assign the delivery of key services to specific staff and ensure that they are trained.

    Developing roles and assigning tasks often begins by listing the common services/tasks required by evidence-based guidelines, and then deciding who on the team should provide them. LEAP practices try to move tasks away from providers by assigning them to RNs, MAs, or laypersons if allowed by state regulations. The goal is to assign tasks so that everyone on the team is working at the top of their license—and not doing things others with less training can do just as well or better. But even if state regulations allow staff to perform clinical functions, the practice must ensure that they have the skills to do so, which may require additional training. 

  2. Use protocols and standing orders to allow staff to act independently.

    If tasks delegated to staff require provider approval and/or documentation, it substantially reduces efficiency and limits opportunities to free up provider time. Pre-approved protocols and/or standing orders reduce the need for provider involvement. They also help make clinic visits more productive by enabling staff to collect relevant data and deliver services before the visit. In many LEAP practices, many preventive services are delivered before a provider sees the patient.

  3. Efficiently generate patient-specific data on services that are due.

    To plan visits, core teams need up to data patient data before the visit. Ideally, the data for each patient would include:
             a. Preventive services needed—dates and results of most recent services received.
             b. Chronic illness services needed—dates and results of most recent services received.
             c. Other service needs.

    Electronic health records (EHRs) vary in their capacity to generate patient-level summary data of this type, but several LEAP sites have aggressively sought help from their EHR vendor or vendor users groups to adjust their EHRs to produce registry-like data or exception reports.

  4. Huddle the core practice team and review patient before clinic sessions.

    The process of planned care begins with reviewing patient data to determine services that are due or overdue. Most LEAP sites have found that it is more efficient to have the team MA conduct the EHR review (“chart scrub”) before the team huddles. In the morning or pre-session huddle, the provider shares priorities and concerns for the visit, the MA reviews the results of the chart scrub, and the visit is planned.

  5. Plan follow-up

    Regular follow-up has been repeatedly shown to improve outcomes, especially when executed by non-provider staff outside of clinic visits. As a consequence, many LEAP sites made time for MAs and RNs to follow up by telephone or secure message with patients seen in the clinic. To ensure that patients are followed up, some teams huddle again at the end of a clinic session to plan aftercare.


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. 

  • 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.

  • 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.

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.

  • 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.

  • 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.

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.

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.

  • 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.

  • 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.

  • 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.