Once staff are trained, Carilion Clinic task shifts within the care team to optimize the efficiency and workflow of their practice and allow everyone to work at top of their license. For example, nurses or non-clinical staff such as receptionists and schedulers can conduct tests and surveys either before or after the planned physician visit. Additional tasks may include providing follow-up education to patients and their caregivers about available community resources.
Patient journey at Carilion Clinic
1. The patient journey at Carilion Clinic starts with the front desk staff.
A nurse or social worker calls the patient’s family to confirm the appointment. They use a modified structured dementia screening tool called the AD8 to ask the family how the patient is doing at home (repetitive behaviors, difficulties with ADL's, can they care for themselves, etc.).
2. The patient then comes into the clinic, or the clinic physician will conduct a house call or video visit.
When the patient comes in, the nurse screens the patient, and the nurse or social worker/aid administers the cognitive testing and geriatric depression screening.
3. There is a huddle with the care team to discuss the intake information before the official exam with the physician.
This ensures that, in the actual exam, the doctor can effectively use their time to make a diagnosis and begin formulating a care plan.
4. Following the huddle and exam, the physician will chat with social worker about next steps and meet with the family.
The social worker handles counseling and support and services, and the physician will typically order up labs, imaging, medications, etc.
5. There is typically a follow up visit in six months on the status of the patient.
6. Patients/families are encouraged to contact the clinic in the event of major changes in status.