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Implementation Worksheet


Develop a preliminary plan regarding the “who, what, when, where and how” for the following tasks:

  • Identifying patients eligible to receive a DA
  • Determining who will recommend DAs
  • Determining who will dispense the DAs
  • Developing and implementing protocol for DA viewing follow-up
  • Developing and implementing the protocol for tracking DA return and patient surveys (if applicable).

1)    Where will the DAs be stored?

  • Will patients be expected to watch the DA in the clinic – or can they take the DA home?

2)    How will you identify patients eligible to receive the selected DAs?

  • When will this occur and how frequently (i.e. will this occur at the start of the week by reviewing patient appointments)?
  • Who will do this work (and will this vary by provider)?
  • Will this process vary based on the DA topic you have selected?

3)    How will you distribute the DA to eligible patients?

  • Will it be mailed before the patient’s appointment?
  • Will the patient receive a “referral” for the DA from the clinician following the patient visit?
  • Will protocols be created so that the medical assistant/care coordinator preps the DA for any eligible patient upon check-in for an appointment?
  • Will the provider distribute the DA or will this task be delegated to others in the practice (i.e., medical assistant, care coordinator, referral coordinator or front desk)?

4)    What will you do if a patient doesn’t want a DA – or you feel that the DA isn’t appropriate for the patient (even if they are eligible)?

5)    Once a DA has been distributed, will you follow-up with patients to make sure they: a) view the DA, b) return the DA & surveys, and c) come in for a follow-up visit if needed?

  • How many reminders will you do?
  • What format will these reminders be (i.e. will you make calls, send a postcard, email, etc.)?
  • Who will do these reminders and when?
  • How will you track that these reminders have been sent?

6)    Once viewed/completed by a patient, how will you collect the DA?

  • Will you schedule a follow-up appointment at the time the DA is distributed (and thus ensure the DAs are returned at this time)?
  • Will you make follow-up calls to patients (similar to tracking if a lab/specialist visit has been completed)?

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