The 18 month Well Baby Visit Queen’s Family Health Team

1. The 18 month Well Baby Visit Queen’s Family Health Team D. Batchelor RN(EC), MScN, NP-PHC; D. Martin BAH, BEd., MA, Clinical Program Coordinator “Children are one third of our population and all of our future.” Select Panel for the Promotion of Child Health, 1981

2. Outline of the Presentation • Overview of the Queen’s FHT and our process • Tools – referral pathways • Evaluation – outcomes, strategies, results, & observations • Next steps

3. Queen’s Family Health Team – Fast Facts • 13 300 patients – approximately 230 babies each year. • 4 clinical teams within two physical sites. • Academic family medicine center – which means lots of residents (50+ PGY1 residents), locums, and other learners (nursing, NP, & medical students). • 23 faculty physicians – or the equivalent of about 9 FTE’s • Other clinical staff – 4 NPs, 2 social workers, 1 pharmacist, 1 dietitian, and 13 nurses (RN & RPN – including 1 lactation consultant, 1 part-time foot care nurse, and 1 part-time after hours clinic nurse). We also have a complement of administrative and clerical staff (reception, billing, medical records, and referrals). • EMR – OSCAR

4. 18 Month Well Baby Working Group • Physician Champions: Dr. Susan Phillips & Dr. Karen Hall Barber • NPs: Lorraine Chick, Kim Mahoney, Jennifer Berry, & Diane Batchelor • RN: Elizabeth Hughson • Clerical: Michelle Little • Clinical Program Coordinator: Danyal Martin Our program relies on a multi-disciplinary team comprised of representatives from across the QFHT – everyone has a part to play!

5. Collaboration & Timelines • Regional role out of the project – partnering with KFL&A Public Health and regional partners in the 18 month project work group • Physician and HCP training • Community education • Implementation in pilot sites • Improving access to services • Linked with “Let’s Read!” initiative • QFHT Implementation • Pilot – June 2010 • Full scale launch – June 2011

6. Our Process

7. Our Process – Identification & Booking • Simple queries were created in our EMR to allow reception to easily identify children at 15 & 18 months. • Reception checks this list monthly and identifies children who should be booked in for their 15 month visit. They confirm that these children are still part of our practice (cleaning up records) and that they are booked in for a 15 month visit and an 18 month visit. • Most visits are completed by an RN/NP and resident, but there are a few that are done by the resident and faculty physician. (We’re working to better capture these.) • Some of our clinical teams hold specialized “clinics” just for the 18 month visit, but others mix them within the regular clinical times. We’ve also experimented with evening visits.

8. Resident Education • Residents are (typically) booked in with their team’s 18 month visit expert (NP or RN) for a one hour visit. • Residents are provided with objectives and a binder of learning materials in advance. • Residents share their experiences in peer-led teaching sessions (“clinical pearls”) and document their activities in log books.

9. Assessment and Follow-Up • Reception provides a copy of the NDDS and M-CHAT to parents. (Parents sometimes struggle with these forms, so reception provides information as best as possible or directs them to their provider.) • During the visit, providers complete the Rourke, a tracking/flowsheet & other appropriate sections of our EMR. • If there are concerns on these forms, or if the parents raise concerns, children are scheduled for a follow-up appointment, a phone call or referral. • Otherwise, children are scheduled for their regular visits at 2, 3, and 4 years.

10. Tools – Referral Pathways

11. Tools - Tracking Advantages • Embedded within the EMR • Data can be queried • Serves as a “checklist” Challenges • Double charting • Completion

12. Evaluation – Many Possibilities • *Completion of cycle of well baby checks (2 months to 18 months) • Identification of delays and why • *Vaccines schedule completion • Completion of Rourke, MCHAT, & NDDS • *Tracking sheet completion • Growth percentiles on target • *Billing completion • *Patient, resident, & provider satisfaction • Early interventions, appropriate referrals, and follow-up *Key indicator

13. Evaluation - Methods • Chart review • Data pull from tracking sheet, as well as demographics, preventions (vaccine module), and the Rourke. • Phone and electronic surveys to patients, providers, and residents • Review of wait times for local agencies

14. Pre- and Post-implementation Audits • Pre-implementation – sample of randomly selected children born from July 2006 to November 2008 • Post-implementation – audit of all wbc from children born December 2008 to November 2009 • What were we looking for? • #identified, #ineligible, #visits/#children • #visits missing, #vaccines incomplete

15. Pre- and Post-implementation Audits • Other areas of concern: • Rourke documentation • Who is completing the visit? • Why are visits being delayed? • Are we following up on issues? • Final weight percentiles • MCHAT & NDDS results & f/u • Tracking sheet completion • Billing • Referrals

16. Pre- and Post-implementation Audits Pre-implementation July 06 – Nov 08 • 101/441 identified for review • 2 ineligible • 99 children/visits • 18 visits missing (18%) • 17 vaccines incomplete (21%) Post-implementation Dec 08 – Nov 09 • 258 children identified • 94 (36%) inactive • 164 children/visits • 7 visits missing (4%) • 13 (7%) vaccines incomplete • 11 (6%) with health or speech issues for recall

17. Observations • Frequent illnesses (OM/URTI/UTIs) interfere with completion of visits/vaccines on time • Rourke frequently not completed: i.e. head circumference, nutritional status, PHE, signing • Medical history frequently not up dated • Infrequent f/u of concerns: i.e. high/low weight percentiles & speech • MCHAT/NDDS did not result in a large number of referrals • Variable wait times for children with deficits in speech • F/u at 24 months not frequently planned • Tracking sheet frequently not completed

18. Next Steps • Changes/upgrades to our tracking sheet. • Develop clearer recall process for those with identified concerns and missed vaccines. • Develop clearer process for visits other than the 15 and 18 month visits (esp. 1, 2, and 24 month visits). • Distribute “diaper tag” promoting 18 month visit at 1 month visit. • Distribute newborn literacy kits at 1 month • Raise awareness of the tracking sheet and the Rourke to ensure better completion rates.

19. Questions? Diane Batchelor – diane.batchelor@dfm.queensu.ca Danyal Martin – danyal.martin@dfm.queensu.ca