Planned Visits

For this ambulatory block you each have a session titled: Planned Visit.

This is a special session that has been reserved for you to see a patient in a different way.  In following the “Chronic Disease Model of Care” – this is an appointment which is meant to be more patient-centered and focused on the needs of the patient.  This means that the visit will be planned for – depending on the needs of the patient.  The patient will prepare and you will also prepare for the visit.

You may choose a patient with Diabetes whom you think would benefit: Pick a patient from your diabetes registry or one that you have seen earlier in the month.  For example:

          A patient who is not controlled

          A patient who is not following up with appointments

          A patient who you feel has obstacles to adherence with medication regimen where spending more time to sort that out may be useful

          A patient who needs to see the dietician and/or diabetic educator in conjunction with your appointment.

Alternatively, you may choose a patient who you think could benefit from a more comprehensive Geriatric Assessment.

          A patient who has had a recent fall

          A patient who appears at risk for functional decline – for any one of a variety of reasons

          A patient with possible or definite cognitive impairment

          A patient where family seems to be excessively burdened by care and not following through on treatment plans

          An elderly patient who appears depressed

          An elderly patient on multiple medications where medication issues may be an important issue

          A patient where you think the social worker could be of benefit to discuss family support, home care, respite programs

          A patient who needs to discuss advance care planning with you.

You would ask a patient to return to your Planned Visit session and follow the steps in the Geriatric Assessment powerpoint presentation:

          As part of your visit you may perform:

Functional Assessment – via ADL and IADL scale

Cognitive Assessment – via MMSE or MIS, or minicog

Assessment of Mood with the Yesavage Depression screen

Assessment of Gait – Get up and Go test

Medication Review with all meds – OTC and prescribed – patient should bring in all meds- “the brown bag visit” – tell them to bring in meds

Social Assessment – interview of caregivers and family

Advance Care Planning and Health Care Proxy discussion

Document these visits as a usual visit but inform the attending supervising that this is your planned visit patient.