1. El Paso First Healthplan, 1145 Westmoreland Drive
Improving Care and Outcomes of High Risk Newborns after NICU Discharge using the Patient Care Navigation Program
Ma Teresa C Ambat, MD
Region 15 RHP Meeting
El Paso First Healthplan, 1145 Westmoreland Drive
September 24, 2014
1:00pm

2. Description of the Project
Establish a Patient Care Navigation Program within the High Risk Clinic, a neonatal follow-up program at Texas Tech University Health Sciences Center (TTUHSC) El Paso - Department of Pediatrics
Patient navigation - a process by which an individual (a patient navigator) guides patients through and around barriers in the complex care system to help ensure that patients receive coordinated, timely, and site-appropriate health care services
Target infants born at < 32 weeks gestational age and/or infants whose birth weight was < 1500 grams – a cohort of high-risk patients discharged from the El Paso Children’s Hospital (EPCH) – Neonatal Intensive Care Unit (NICU)
Our solution was to implement a patient navigation program within our existing structure.

3. Patient Care Navigation Strategic Plans
Road map to navigate toward success
Steps
Timeline
Status
Step 1: Analyze the role of the patient navigator
August – December 2013
Completed
Step 2: Identify Our Existing Strengths
August – December 2013
Step 3: Identify Our Challenges
August 2013 – DY 5 (2015)
Ongoing process as new challenges surface during the implementation of the project.
Step 4: Develop the Bones of Our Navigation Program
August – October 2013
Basic structure for implementation of the program has been completed. Subject to modification as needed in adherence to quality improvement process.
Step 5: Develop Outreach Plans to Enroll Patients and Promote Retention
DY 3 (May 2014) – DY 5
Ongoing process.
New strategies will be implemented as they are identified.
Step 6: Initiate the Navigator Role
DY 3 – DY 5
Ongoing process
Step 7: Growing Our Patient Navigation Program
Goals for DY 5

4. Project Milestones and Metrics – DY3
P2.1: Number of People 
Trained as Patient Navigators
Goal: 1 Additional Patient Navigator hired and trained
Person hired – start date 8/20
P2.2: Develop Outreach Plan to enroll patients in Navigation Program
Goal: Complete Patient Outreach Plan
Completed and submitted 8/7
P-10.1: (Customized) Report on types of services provided to high risk patients enrolled in the program
Goal: Complete report on those services provided to High Risk Patients
Care navigation services form created in EMR at Texas Tech Clinic (June).
Navigators use the EMR form to document the services given to enrolled patients (started in June).
IT support uses an identifier to track this form to generate the report.

5. Outreach Plans
Outreach Plans to Enroll Patients and Promote Retention
Patient navigator will arrange meetings with families of patients enrolled in the program and establish relationship prior to NICU discharge.
Provide information on High Risk Clinic Follow up program to help families understand importance of follow-up programs and its impact on long-term outcomes to encourage compliance.
Promote patient navigation as a process/service that will help ensure that patient’s receive culturally competent care that is also confidential, respectful, compassionate and mindful of patient’s safety.
Patient navigators will participate in the discharge process at EPCH – NICU and help NICU team prepare families for the next phase of care.
Conduct follow-up phone calls 2 weeks after NICU discharge and after each High Risk Clinic visits.
Phone call reminders prior to High Risk Clinic visit.

6. Outreach Plans
Outreach Plans to Enroll Patients and Promote Retention
Provide arrangements for transportation to and from High Risk Clinic appointment.
Address and accommodate for other barriers (daycare, work schedule, health insurance etc.) that keep patients from keeping their follow-up appointments.
Provide incentives to promote compliance with follow-up such as age appropriate toys and books for every follow-up visit kept.
Educate the community about our High Risk Clinic Follow-up program and our new navigation program by meeting with community providers.
Leave flyers at Pediatric offices in the city to encourage follow-up.
Hire and train an additional patient navigator to provide services to accommodate the increasing number of patients enrolled in the program.

7. Navigation Services June July August September Total Total Services 16
154 93 63
297
Top 5 services
Care Coordination – High Risk Clinic 1 12 5 23
Care Coordination – PCP 14 9 25
System navigation – DME issues 6 10 29
Apnea monitoring 20 11 44
Phone calls – prior to High Risk clinic visit 27 59
Other services: care coordination for subspecialty ff-up, barriers to access, education on appropriate use of services, insurance services, phone calls – 2 weeks after NICU discharge, prescriptions, social services, home health, referrals to ECI and other rehab facility, triage medical problems, etc.

8. Project Milestones and Metrics – DY3
P-8.1: Participate in 
semi‐annual face- to-face
meetings or seminars
organized by the RHP
Goal: Participate in at least two (2) face-to-face meetings /seminars
1st meeting: 7/30
2nd meeting: 9/24
I-10.2: Increase Number of 
Unique Patients served by 
Navigator Program
Goal: 30 patients (QPI)
(Compliance with first High Risk Clinic appointment)
50 – QPI as of 9/16
(Total number of target patients recruited for DY 3 = 74)
Request to change QPI for DY 4 and DY 5 – submitted in August
I-10.2: Increase Number of Unique Patients served by Navigator Program – DY4
Goal: 55 patients (QPI)
I-10.2: Increase Number of Unique Patients served by Navigator Program – DY5
Goal: 60 patients (QPI)

9. (4 patients had CSBS-DP at 12-13 months, not counted)
Category 3 Measures
IT Developmental screening in the first 3 years of life.
Indicator: The percentage of children who had screening for risk of developmental, behavioral and social delays using a standardized screening tool documented by 12 months of age.
Denominator: Target patients who turn 12 months of age between Jan – Dec of measurement year.
Targeted patients: Premature infants enrolled in the program (< 32 weeks and or birth weight < 1500grams).
Communication and Symbolic Behavior Scales Developmental Profile (CSBS-DP) – performed during high risk clinic visit on target patients (<32 weeks and or < 1500 g) starting at 9 months chronologic age (started in June).
CSBS-DP screening is incorporated in EMR – High Risk Clinic visit form for documentation and tracking.
Total number of targeted patients who turned 12 months from January to September of measurement year 19
Dropped out before 9 months 6
Total number of targeted patients who received developmental screening using CSBS-DP
6/13 = 46%
(4 patients had CSBS-DP at months, not counted)

10. Category 3 Measures
IT 9.9. Transition record with specified elements received by discharged patients.
Measure: Percentage of patients who received transition record at the time of discharge.
Targeted condition – Premature infants < 34 weeks admitted and discharged at El Paso Children’s Hospital – NICU must have documentation of receipt of transition record.
Transition record entered as an event by residents/NNPs at discharge (started in June). Tracking done monthly.
Total patients Discharged < 34 weeks GA
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Total 3 11 15 7 5 10 8 9 12
Pend 92
Patients with documented receipt of transition record 4 24
Patients with documented receipt of transition record (%)
44%
92%
100%
26%

11. Category 3 Measures IT 8.25. Sudden Infant Death Syndrome Counseling
Measure: Percentage of children 6 months of age who had documented Sudden Infant Death Syndrome (SIDS) counseling.
Numerator: Children who had documented SIDS counseling within 4 weeks of birth or by first pediatric visit, whichever comes first.
Denominator: Children who turned 6 months of age during the measurement year.
Targeted facility. All infants discharged from the El Paso Children’s Hospital – NICU.
SIDS counseling incorporated in discharge teaching on all infants discharged from the El Paso Children’s Hospital – NICU.
SIDS counseling is entered as an event in Site of Care by residents/NNPs for documentation (tracking started in June).
Total patients discharged from EPCH-NICU
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sept
Total
101 97 87 72 69 99 64 78
102
Pend
955
Number of patients who received SIDS counseling 49 91 90
230
Number of patients who received SIDS counseling (%)
56%
92%
88%
24%
Baseline data of 0% will be reported in September (None of those patients who received SIDS counseling from June onwards had turned 6 months. The above data will be included in the next reporting period in April).

12. Questions?
Comments?