2010 Audubon Pediatric Practice Quality Improvement Project May 26, 2010

AIM Statement: To increase the percent of Audubon pediatric patients who see their primary care provider at scheduled visits from 53% to 80% by the end of the 2009-2010 academic year (June 2010)

Practical Basis This project stems from our experiences throughout the hospital. Practically and anectdotally, I think it is fair to say that the Audubon pediatric residents know the frustration of a completely unfamiliar panel of continuity clinic patients. We have all run to clinic frantically from the wards only to wonder how former resident Daniel Vo has once again approved our 10:20 overbooking. This project is also motivated by our experience in the ER. We do a fair amount of primary care there, and this insurance card might explain why.

The Medical Home 1967 – AAP was the first to introduce the concept; initially referred to a central location for archiving a child’s medical record Medical care of infants, children, and adolescents that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective Involves a physician that is known to the child and family, and is able to develop a partnership of mutual responsibility and trust We also find strong support for this project in the medical literature. At its heart, this is effectively a QI project about the importance of the medical home, a concept that was first introduced in the 1960’s whichrefers to the central location of a child’s medical records. This definition has expanded to a central location where medical care is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective. The medical home demands clinicians to be well trained and to participate in all aspects of that care. AAP POLICY STATEMENT (initially published: PEDIATRICS Vol. 110 No. 1 July 2002, pp. 184-186; reaffirmed August 1, 2008)

Theoretical basis CSHCN have better outcomes than children receiving care in a non-medical home (Homer et al., 2008) Medical Home offers cost reduction, particularly for those with chronic disease If done correctly, the medical home delivers high quality, cost-effective care.

Background Data Paired Correctly NOT paired correctly Total Visits Percent Paired Correctly Resident 40 36 76 53% Attending 62 32 94 66% Total 102 68 170 60%

Background Survey Low PMD Awareness Visit Scheduling: 60% of visits scheduled within one month of appt. PMD Availability: 50% were always able to schedule appointments with their PMD In Block 2, Bram and Jen surveyed patients and identified 3 issues that contributed to incorrect PMD-patient visits. They found a low number aware of who their PMD was, that about half were able to schedule an appt with them always, and that visits are often scheduled a month prior to the visit. A visit made 1 week prior for a first-year resident wit 6-7 clinic appts/week is likely not going to be with that resident.

How a Clinic Appointment is Made? PFA Call Center ER

PDSA P: Increase correct PMD-Patient visits by identifying PMD in Eclypsis D: Designate PMD in Eclypsis We started to try to improve our PMD visit rates by creating an electronic notation of PMD in Eclypsis. Jakie and Genevieve bravely tried to include another step into an already crowded clinic visit. Further, they educated the PFAs that the PMD could know be found in Eclypsis and to look here when scheduling future visits.

Study Total Patients Seen PMD Designated Mid-Block 26 3 (12%) End-Block 56 10 (18%) Aki and Janniene, in addition to educating us about the importance of the medical home, studied how frequently we were designating ourselves as PMD. “To be honest with you, I haven’t added any of my patients during the last block... feels bad.”

Act Abort Eclypsis PMD designation PMDs only sporadically self-identifying in Eclypsis Neither PFA nor call center utilized this information when making appointment  Future Plans: Devise other methods of identifying PMD Re- survey the appointment process PFA at our clinic - not opening Eclypsis when patients call to book appointment Time consuming.  Hard to change their routine. often time, visit history in Epic will tell you who is PCP. at the end, asking patient who is their PCP gives them an answer.  Call center Moving on to a new appointment online- system (with unknown schedule) Asking patients who is their PCP.

How to Identify PMD? Business Card? The Face sheet? The Welcome sheet! Need to scan welcome sheet and business card. Finally settled on a standardized welcome sheet

PDSA P: Increase PMD awareness by distributing Welcome Sheet at each visit D: Survey residents as to how often Welcome Sheets are provided by PFA S: 1 handout in 24 patient encounters A: How to improve Welcome Sheet Distribution? Welcome Sheets placed in clinic rooms Increase family awareness of providers in other ways Survey Families \.

PMD Photos

Family Survey 10 families questioned in waiting room after visit 0 received Welcome sheets 5 could name PMD immediately after visit All relied on call center to identify PMD when making an appointment. 7 said they would take appointment with first available provider if more convenient  

Final Results To increase the percent of Audubon pediatric patients who see their primary care provider at scheduled visits from 53% to 80% by the end of the 2009-2010 academic year (June 2010) A chart review was completed on 147 patients during April 2010

Final Results Paired Correctly Not paired correctly Total Visits Percent Paired Correctly Resident 41 23 64 64% Attending 65 18 83 78% Total 105 43 147 71%

Future Directions Challenges Continue to distribute Welcome Sheets Call center? Challenges Multiple systems that do not communicate Patient literacy Further limitations on resident availability

Update Post partum depression AIM Statement: To screen 95% of mothers of patients less than 4 months of age for post-partum depression A chart review of 69 patients aged 0-3 months was completed during 2 week period in March 2010. 59 patients were screened for post-partum depression (86%)

Thank you Thank you to Audubon PFAs, MAs, RNs, Residents, Fellows and Attendings Special Thanks to Connie Kostacos, Mariellen Lane and all the other ACN Clinics

Provider Survey 14 residents and 2 Attendings Majority distribute Welcome Sheet either “rarely/never” or “around 20% of time” Majority indicated that they either simply forget to distribute or could not find in rooms Majority indicated that Welcome Sheets should be handed out at every visit 50% thought PFAs should distribute; 25% both.