Journal of Community Medicine & Health Education
Open Access

Pre-visit planning is an anticipatory focus on the care that will ensure each patient visit is well-organized by removing administrative duties from the patient’s appointment time. Allowing clinical staff to focus on the patient during their visit provides comprehensive and quality care (Empire BlueCross BlueShield, n.d). Pre-visit planning can save time and money and improve patients' overall office visit experience (National Institute of Diabetes and Digestive and Kidney Diseases, 2019). The patient visit lasts about 121 minutes, with only about 15 minutes spent with the provider. According to new research, doctors spending more time with the patient to see better medical outcomes gain the patient's trust and close healthcare gaps [1].

A need assessment was conducted using a chart audit at a community health center where 45 charts were reviewed and the findings were that 80% of the charts showed that the patients' health maintenance was not updated. These results were further discussed with the pre-visit planning team and preceptor, who identified that missed preventive screenings caused a gap in the patients’ healthcare and limited access to healthcare services [2]. This need assessment was followed up with a literature review which showed pre-visit planning could bridge the healthcare gap (National Institute of Diabetes and Digestive and Kidney Diseases). Therefore, an innovation aimed at implementing pre-visit planning in the community health setting was developed using the connectivism learning theory.

This innovation, guided by connectivism learning theory, utilized a flipped-classroom approach to increase clinical staff members' pre-visit planning abilities. Ultimately, this project will help improve patient outcomes in the community health setting.

Literature Review

Description of Innovation

The pre-visit planning innovation project was implemented to address the priority learning need of pre-visit planning. The educational project was delivered to registered and licensed nurses, certified nurse's assistants and medical assistants and guided by connectivism learning theory. The project also used flipped classroom learning strategies, facilitated discussion and think–pair–share. This activity allows learners to work in a collaborative setting.

Connectivism Learning Theory emphasizes using technology to help adult students learn independently outside of the traditional classroom setting [3]. Using online and face-to-face learning environments, learners, was exposed to a flipped classroom to encourage motivation and engagement, bringing knowledge learned outside of the classroom and applying it within [4]. The benefits of connectivism learning theory are the diversity of learning, knowledge and decision-making. Some challenges of connectivism learning theory are to have accurate and up-to-date information and access to the internet.

This project utilized the flipped classroom that switches the learning setting as learners do some learning outside of the class. The author further states that learners tend to respond to a flipped classroom, which positively increases motivation, engagement and learning. A disadvantage of a flipped classroom is that it requires technology access, which may cause an accessibility gap [5-8]. Before the lesson, learners completed a computer module on pre-visit planning through a Relias© e-Learning training program. This computer module covered information including immunization orders, updating health maintenance, proper appointment notes documentations and learning was evaluated with a posttest.

During the in-person lesson, learners participated in a facilitated discussion and think-pair-share activities with the educator. Facilitated discussion and think-share-pair helped evaluate the learner’s needs and promote brainstorming for pre-visit planning implementation. According to Raba, think-pair-share improves students' critical thinking skills, listening and enhancing reading comprehension skills, collaboration and prevention skills. Think-pair-share aid learners in processing information and improving open dialogue. The disadvantage of think-pair-share and facilitated discussion it forces the learners to communicate in an open group setting and may put added pressure on the learner.

The interprofessional collaborative partners all played an active role in the pre-visit planning process. They included clinical staff (registered and licensed nurses, certified nursing assistants, medical assistants), pharmacy staff, lab staff, social workers, clinical managers and clinical nurse leaders.

Presentation and interpretation of assessment/evaluation data

The pre-visit planning innovation project's intended outcome is that the clinical staffs are educated and implement the pre-visit planning in the everyday workflow. The pre-visit planning innovation was presented to 26 clinical staff members in a classroom setting at a local community health center. The training material was presented via a Microsoft word document with picture graphics. The educational information was taught to the clinical staff with step-by-step instructions and allowed the learners to practice each step in a practice environment as the instructor covered the information.

According to Dr. Usun, computer modules are highly efficacious for adult learners because adults have self-direction, problem-centered, and have a diversity of experience. The clinical staff in the community health setting completed a computer module training program via a flipped-classroom approach and completed a posttest before attending the educational session for the innovation project. A passing score on the posttest was the clinical staff prerequisite for attending the pre-visit planning information session.

A case study was developed for the innovation and was implemented in a face-to-face classroom setting. Case studies have been highly beneficial in providing learners opportunities to apply their skills [9-10]. To ensure grading consistency and goal attainment, a rubric was developed [11]. All learners were successful in completing the case study, showing their ability to apply pre-planning visit education.

Questionnaires are highly efficacious evaluation tools and were used to glean the learners' experience by asking open and closed questions. The questionnaire showed that ninety-eight percent of learners indicated the innovation was very effective in teaching the clinical staff in a community health setting pre-visit planning techniques to use in the everyday workflow. Ninety-five percent of the clinical staff admitted their team does not update health maintenance as often as they should. A hundred percent of the clinical staff member stated that all team members should be responsible for completing pre-visit planning. Ninety-eight percent strongly agree that the educational training is beneficial to their daily job responsibilities. A hundred percent of the clinical staff somewhat agreed that the educational presentation contained practical examples and valuable techniques applied to current work [12-14].

The evaluation tools implicated that the learners gain the knowledge they needed to implement pre-visit planning in their workflow. However, the open and close questions questionnaire results indicated continuing education needs. The questionnaire identified some of the barriers the clinical staffs have in continuing pre-visit planning: pre-visit planning is time-consuming and at times they are short-staffed.

Implications of the Innovation

After Meeting with the pre-visit planning team, preceptor and analyzing the open and closed question questionnaire results concluded that continuing education is needed so the clinical staff will continue to implement pre-visit planning in the community health setting everyday workflow. Continuing education will involve reviewing the literature about the pros and cons of pre-visit planning in a community health setting, re-introducing the pre-visit planning workflow, step-by-step process with each clinical team and continued pre-visit planning workflow in the clinical setting. Pre-visit planning innovation projects positively impact nursing and health education by closing health care gaps for patients, increasing the quality of care by identifying worklist items and care needed at the appointment and giving the patients satisfactory access to health care options [15].

Discussion

The relevance of pre-visit planning in a community health setting is to improve communication between the clinical staff and patients, improve patient' health outcomes, and close gaps in healthcare [16-18]. However, clinical staff finding the time to complete pre-visit planning will continue to hinder implementing pre-visit planning in the everyday workflow. Future teaching of the pre-visit planning innovation will involve classroom training and in-clinic training for the clinical staff. In –clinical training will allow the learners to apply their knowledge in a professional setting and help them understand their professional responsibilities. The pre-visit planning workflow will be updated as needed to keep up with technology advancements. The pre-visit planning innovation will become part of the orientation training for clinical staff at the community health center where the chart audits were conducted [19-20].

Conclusion

A learning need assessment identified that pre-visit planning was a priority learning need for the clinical staff in a community health setting. The innovative project pre-visit planning was introduced using the connectivism learning theory and pedagogical learning through flipped classrooms, facilitated discussion, and think-pair-share. The learning assessment and evaluation were completed through an open and closed question questionnaire, and a case study scenario with a pass/fail rubric. The case study and questionnaire results indicated that the clinical staff learned the education for implementing pre-visit planning in the everyday workflow. It was implemented in the everyday workflow; however, continuing education is needed to continue implementing the workflow due to time management and staff shortage. Future pre-visit planning training sessions will take place in a training environment and in-clinic setting. The pre-visit planning innovation training will be a required orientation tool at the community health center where the audits took place. The pre-visit planning innovation project met the outcome of implementing pre-visit planning in the community health setting everyday workflow.

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