Before the patient visit, the student team should review the medical records and work with the home visiting professionals and/or preceptors to determine the goals of the patient encounter.
The preceptor(s) will determine what type of patient and/or family/caregiver encounter for the student team is appropriate. The patient visit may be a home visit, which can be conducted with a social worker or nurse, with overall supervision by the practice preceptor, depending on the types of students and the accreditation parameters. The visit may also take place in the office setting, long term care facility, hospital, correctional institution, homeless shelter and/or other appropriate setting.
Factors 1, 2, 3 and the relevant parts of Factor 4 from Standard 4 Element B, Care Planning and Self-Care Support are addressed in the patient and/or family/caregiver visit. For instance, the visit should include the student team working collaboratively with the patient and/or family/caregiver to develop and/or update an individualized care plan that includes:
- Patient preferences and functional/lifestyle goals (Factor 1)
- Treatment goals using evidence-based guidelines (Factor 2)
- Assessments of potential barriers to meeting treatment and functional/lifestyle goals, which may involve working with other providers and community resources, in addition to the patient and/or family/caregiver (Factor 3)
- A self-management plan that includes instructions and resources to address barriers identified in Factor 3 as well as goals and ways to monitor self-care, and if treatment goals are being met, documentation of and instructions to maintain current self-care plan (Factor 4) — note that the full plan will be completed during the Report and Presentation Section 6
- Strategies for addressing potential barriers to meeting goals
- Documentation of the care team members, including the primary care provider of record and team members beyond the referring or transitioning provider and the receiving provider
- Services offered by and responsibilities of the primary care practice
- Appropriate and non-redundant aspects of care plans created for the patient by non-primary care practices
- Current problems (may include historical problems, at the practice’s discretion)
- Current medications
- Medication allergies
CMS defines a care plan as, “The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).”
Although much of the process of active care planning can be carried out at this student visit, in most cases, finalizing the plan will not take place until the student team meets with the practice team to review and revise the preliminary plan presented by the students.
As far as is appropriate to their profession and the visit setting, the assessment will involve interviewing and conducting a physical exam with the patient as well as interviewing family members/caregivers.
- Self-Management Support AHRQ (with links to additional resources)
- Video on Coaching Patients on Self-Management (California Health Care Foundation)
- Video on Motivational Interviewing IHI
- PPT Overview of Motivational Interviewing SAMHSA-HRSA Center for Integrated Health Solutions
- Motivational Interviewing Reminder Card (11 reminders for providers about MI)