Proactively Manage your High-Risk List
Establish a mechanism to track high-risk patients and reach out to them more frequently.
Best practices:
- 1. Convene a regular team huddle to discuss the high-risk list
-
The huddle represents an opportunity for the team to review and update the high-risk list as well as create action items for the week ahead. Most clinics felt that a brief, weekly, 15-to-30-minute huddle was critical to keep the team engaged, stay organized, and maintain momentum.
- Tip 1: Ensure appropriate and necessary team members are present. The team usually includes: the provider(s) who treat(s) the high-risk patients as well as those team member(s) responsible for managing the high-risk list and reaching out to the high-risk patients.
- Tip 2: Establish a set day and time. Most clinics stressed the importance of scheduling the huddle at a specific day and time each week to ensure that it takes place. Make a specific team member responsible for scheduling the meeting and adding it to everyone’s calendar.
- Tip 3: Make it easy for everyone to attend. Some clinics sent huddle reminders or held virtual huddles so team members could participate from wherever they are.
- Tip 4: Squeeze it into an existing meeting if you can. Some clinics found it easier to carve out 15 minutes of an existing meeting to discuss the high-risk list or add an additional 15 minutes onto an existing meeting where the necessary team members were already present.
- Tip 5: Set the huddle up for success. Put one person in charge of running through the high-risk list during the huddle. This person decides when it is time to move onto the next patient (to keep the huddle running on time) and the one who delegates tasks to other team members. Put one person in charge of taking notes on what tasks were agreed upon and who is responsible for completing the tasks. These persons may or may not be the same team member.
- Tip 6: Make it a priority. If it is not made a priority, then it will never happen.
Examples:
Baylor College of Medicine - “We conducted weekly 15-to-20-minute huddles, bundled with research meetings. We usually met with the team on Thursdays at noon. The most important thing is the huddle. If you do not have the huddles, you do not keep people engaged and you cannot track what you are doing. It is easy for things to fall away if it is not constantly in your face.” Cedars-Sinai Medical Center - “It would take five minutes to run through the list at the weekly huddles with the nurse navigator and say, ‘Can you please check in on this patient, this patient, and this patient.’ The nurse would then check-in on the ones that needed to be checked-in on. I thought that was SUPER helpful. The weekly huddles allow for organization, reflection, and a chance to review stats and data. They are helpful for creating action items for the upcoming week, as well as in maintaining an up-to-date high-risk list.” Gastroenterology Associates, Inc. - “One of the students or residents would manage the high-risk list and we would go over it together during the huddle. Every Thursday at 6:00 pm we have our team meeting virtually by Zoom, and we go through the ‘Hot List.’ Because there are several team members on board, we will alternate – one person pulls up a patient for discussion, and while discussing, the other staff member is pulling up the second patient. In this way, there is no downtime while reviewing. We can usually run through the list in 5 to 10 minutes. In the beginning it was hard to meet on a regular basis because we tried to meet in-person. What solved it was COVID because we went to virtual meetings. The virtual meetings have been good because most people can attend, and we can change it on the fly. Meeting weekly keeps you focused on the projects. It is really critical.” - 2. Define next steps (i.e., create an “urgent care plan”) for each high-risk patient
-
Meet with your team to create actionable next steps that are specifically tailored for each high-risk patient’s unique need(s).
- Tip 1: Make the next steps clear, task-oriented, and time-bound to eliminate uncertainty.
- Tip 2: At a minimum, make sure that each high-risk patient has a follow-up appointment scheduled. If not, it should be first priority.
Examples:
NYU Langone - “Me and the nurse met each week to go over the high-risk list – whether it was making sure the patient had a follow-up scheduled for next week, got on a specific medication, or, if it was a patient with severe anxiety and depression, that we checked-in with them once a month to make sure they are doing OK. During the huddle, we would make sure to run through the list as well as the action items for each patient.” University of Colorado - “My advice would be to make it clear who is responsible for it and have realistic expectations. For example, have discrete tasks for patients on the high-risk list so you are not confused as to why the patient is on the list and it is clear what you are supposed to be doing with that patient. Accountability is also important. How we hold people accountable is by having a weekly meeting and reviewing the list, so it is clear when something (a task) hasn’t been done. For example, ‘Did you check to see if the patient got their infliximab scheduled?' 'Did you call them after they were discharged to ensure they were tapering prednisone?'” - 3. Reach out to each high-risk patient on a regular basis
-
Once next steps are identified, reach out to the patient on a consistent basis to assess how they are doing, answer any questions they may have, or schedule follow-up appointments as necessary. Reaching out more frequently (and/or scheduling appointments to see your high-risk patients more consistently) will help address issues before they potentially result in a trip to the hospital or emergency room.
- Tip 1: Make a specific team member responsible for each next step or task to ensure it gets completed. Most clinics assigned a nurse (ex. RN, Nurse Navigator, Case Manager, Infusion Nurse, or Nurse Practitioner) to reach out to high-risk patients.
- Tip 2: Tailor the mode of communication to the patient and the issue. If the patient likes (or prefers) to use the electronic medical record portal for communication, use the portal. If the patient prefers the telephone, use the telephone. Although the mode of communication varied by clinic and patient, most clinics reached out to their high-risk patients via telephone.
- Tip 3: Tailor the frequency of communication to the issue. Some issues require more frequent follow-up. Although the frequency of outreach to high-risk patients varied, most clinics chose to reach out to their high-risk patients every week or every other week until the patient was no longer considered high-risk.
- Tip 4: Let the high-risk patient know that a team member will be reaching out regularly, as well as which team member will be reaching out and how often. Some clinics found it helpful to prepare the high-risk patient for more frequent communication so that the patient would expect it and, therefore, be more likely to respond.
- Tip 5: If possible, have the same staff person reach out to the same high-risk patient. Some clinics indicated that keeping the staff member consistent helped the patients be more open and feel more comfortable discussing their issues.
- Tip 6: If the patient is not following up with your messages, have their medical doctor (gastroenterologist) give them a call. Some sites felt that by doing so it increased the likelihood that the patient would call back and made the team members responsible for reaching out to the patients feel supported.
Examples:
Saratoga Schenectady Gastroenterology Associates - “Our RN proactively manages the highest risk patients by calling them as often as needed. For example, it might be daily if a patient is rapidly declining or very anxious, weekly, bi-weekly, or monthly. This is determined on a case-by-case basis by the RN. We would often make a plan with the patient in terms of how frequently they would like to be contacted. As a result, patients felt more involved in their care and had less concerns. Follow up would be by phone and office visits. We would set a time and date with the patient for contacting them (ex. ‘What day and time works for you?’). Therefore, the patient would expect the call.” The Oregon Clinic Gastroenterology East - “Once a patient is identified as high-risk, we have two dedicated RNs (also infusion nurses), who serve as nurse care coordinators, call the patient. Patients are called weekly to every other week depending on clinical issues. As they continue to improve, we will increase it to every 3 to 4 weeks, and hopefully get them off the list at that point. We also made it a point that the patient has an office visit within 2 months of being added onto the high-risk list. We are contacting high-risk patients predominantly through phone calls. Phone calls can be a bit of an issue because there is some phone tag. But there aren’t too many patients that do not respond.” The Oregon Clinic Gastroenterology South - “Our RN is calling these patients regularly and documenting answers to a list of preplanned questions. They are then relaying the answers back to the provider. It has helped our site to have a template of questions that we ask high-risk patients when we reach out to them so that there is consistency, irrespective of the nurse that is managing the list and making outbound calls. The answers to these questions are what we as physicians need to use.” The Oregon Clinic Gastroenterology South - “The nurses do a good job setting expectations with the patients by telling them that they are going to call them every week. What has helped is when the physician gives the patient a bit of a heads up, ‘We are going to have our nurse follow up with you for a few weeks to make sure your symptoms are doing OK, etc.’ This sets the nurse up for success. So, when the nurse calls, the patient knows why they are calling and is expecting it. The script I usually give as a provider is, ‘I am really worried about you. I am going to have one of my nurses who is well trained in IBD call you because I know I won’t be able to see you every week. Please use them as a resource to move your care forward.’ Most of the patients are relieved that they are going to have someone helping them navigate the system.” Regional Gastroenterology - “Our nurse calls our ‘High 5 List’ weekly or bi-weekly. What works well is that the patients get extensive, repeated education about how they should manage their current symptoms and issues. What also works well is that the patients receive very good, purposeful listening as well as good disease management therapy from our nurse. Time is often something we don’t have with our patients. So, the patient gets more time to be listened to, on a level they have not experienced before and are not accustomed to. It allows them to better manage and utilize the health resources that are available to them.” The Oregon Clinic Gastroenterology East - “We learned that patients would say they feel most comfortable talking to the same person or the same few people about their IBD. The patients felt that the nurses knew them. So, usually it is the same nurse reaching out.” - 4. Implement a tracking system
-
To stay organized, most clinics found it helpful to track the patients on their high-risk list. Some clinics also chose to track additional pieces of information for each high-risk patient, such as: medical record number, reason for being on the high-risk list, next steps, when and how often the clinic reached out, etc.
- Tip 1: Use the tracking system that works best for your clinic and team. To track high-risk patients, most clinics used their electronic medical record system or an Excel spreadsheet. Clinics cited pros and cons of both systems, so choose the one that best fits into your workflow.
- Tip 2: Try to make the tracking system accessible to everyone on your team (or as many persons on your team as possible). By expanding access to the tracking system, it gives all team members the ability to easily edit the tracker. Only allowing the team member responsible for managing the list to have access can create a problem if that team member is ever out of the office.
- Tip 3: If using a system outside of the electronic medical record, be sure you are taking the necessary steps to protect the patients’ personal health information. For example, implement various layers of password protection when necessary.
Examples:
Gastro One - “We are using an Excel spreadsheet that is managed by the Nurse Navigator. It is a good tool because everything is there on one sheet: their chart number, what the big concerns are, whether they are on steroids, if they are pregnant, etc. It is easier this way rather than having to sift through the electronic medical record. It is quick and helpful to use even when a patient calls us.” Cedars-Sinai Medical Center - “We originally created a high-risk Excel sheet to review every week, which listed the high-risk patients as well as the reason the patient was on the list. But that process changed. We went from Excel to Epic. Having a separate program (like Excel) on your screen is hard. The benefit of Epic is that it’s available wherever you are. However, we did lose something with the transition to Epic. In Excel, we were tracking certain things, such as why the patient was on the high-risk list, the patient’s outcomes, etc. With Epic, we lost the ability to track. The only thing that Epic allowed us to do was to have an accurate, available, up-to-date list at all times. To implement this tracking in Epic would require a lot of customization.” MedStar Health - “We created a shared drive with an Excel sheet that we can update with high-risk patients. Maybe inputting it into the EHR would be better. But, getting anything implemented into the EHR is difficult. It would be nice to have some of it a little bit more automated. However, I think overall our Excel method worked for our team. One of the keys about the list is having it be easily accessible. I would recommend finding a user-friendly, easily accessible, HIPAA-compliant shared drive, or something that works for your team.” Dartmouth-Hitchcock Medical Center - “I had an Excel spreadsheet for a while, but then we just built it into Epic on a shared ‘Patient List.’ We switched because Epic is easier – it can be shared by everyone, you know you are always looking at the most updated version, you can easily access the patient chart, and it is not outside of the EHR.” University of Colorado - “We created a high-risk list in Epic for task-directed case management. IBD providers and/or RNs will identify patients to be added to the list. High-risk tasks (also known as a “short-term plan”) will be identified for each patient and added to the list. Case managers will review the list each week and ensure issues/tasks are addressed. Tasks for the short-term plan are documented on the “Specialty” portion of the “Snapshot” page of Epic. Calls with patients are documented as a triage note in the electronic medical record and providers are updated. We have one big Patient List, but it is divided by provider. Our nurse case managers monitor the list. We all have weekly meetings with our case managers and run the lists. The pros are that we are all very familiar/comfortable with Epic. It is easy to pull-up. When I do my meeting with my nurse, we just pull the list up quickly in Epic.
On our high-risk list we have several columns: name, medical record number, currently admitted, and specialty comments. The specialty comments tab is the first thing you see when you pull up a patient’s chart. We keep the Task List in the specialty comments – so it goes into the patient’s chart. However, it is not part of their medical record, so it is not discoverable. On our high-risk list, in the Patient List function, we have the specialty comments as a column. We have the provider’s name and the date the patient went onto the high-risk list listed at the top so that we can easily sort the high-risk list by provider. I would recommend this methodology and Patient List functionality for other sites who use Epic. The benefits are that it is all in one place and everyone can see it and find it. For example, the nurse navigators that are cross-covering can easily find it - it is not living in a silo somewhere.”
Saratoga Schenectady Gastroenterology Associates - “Everyone had their own method. Some nurses use pen and paper while other nurses use a spreadsheet. It was difficult to find a methodology that worked for all three triage nurses. So, we just had each triage nurse use the method that worked best for them. The nurses meet twice a week to discuss what is going on with their high-risk patients. The spreadsheet includes: patient name/phone number, provider initials, date of last contact call, date of next office visit, and a check box for the reason they are high-risk (ex. started prednisone or ER visit).”
Resources:
- High-risk list in Excel
- Creating a high-risk list in Epic
- PDF – Proactively manage your high-risk list
This project is supported by a grant from The Leona M. and Harry B. Helmsley Charitable Trust.
