Improving Practitioner Continuity at Rangel Clinic

1. Improving Practitioner Continuity at Rangel Clinic Betty Reyes, Taina Sanchez,PFA Staff, Call Center Staff Evelyn Berger, Hetty Cunningham, Christine Krause, TawanaWinkfield ElshadeyBekele, SandhyaBrachio, Kathleen Brennan, Alicia Chang, Jamie Harrington, Jillian Hochfelder, Karen Lee, ToluOnigbanjo, Laura Perreta, PeltonPhinizy, Lauren Sanlorenzo, Ronald Zviti

2. Case Example • LS, an 8 year old girl with no sig PMHx, last seen by her PCP, Dr. Primary, 7 months ago for WCC and then by Dr. OutRes 3 months ago as a walk-in for fever/sore throat. • At visit with PCP, patient was instructed to RTC in 1 year for continued WCC and this was documented in the note. • LS does not have a ‘Primary’ Care Provider designated in Eclipsys. • An RTC order was not placed during WCC visit. • The note was not labeled WCC under Document Name.

3. Case Example • It is now September 2011. LS’s mother calls the Call Center for an appointment for a full physical/school form completion. She does not recall the name of her PCP nor the date of her last visit. • Call Center PFA is unable to find a ‘Primary’ designation in Eclipsys. • The PFA discovers that the patient’s last visit was as a walk in with Dr. OutRes 3 months prior. • Unable to determine the date of the last WCC visit or the name of the patient’s PCP, an appointment is made with Dr. OutRes in November.

4. Initial Data Collection Table 1a: Baseline Data * Number of patients discharged from clinic over 20 day period ending 9/29

5. Initial Data Collection • One week period between 8/31/11 – 9/7/11: • 20% of scheduled patient visits were later identified by providers to be untimely WCC according to AAP periodicity schedule. • 56% of patients were scheduled to visit with their Primary provider.

6. AIM Statement • Increase the number of scheduled patient visits with the correct Primary Care Provider (PCP) from 56% to 75% by: • increasing the percentage of patients with a designated PCP from 64% to 80% and, • improving PCP schedule availability by decreasing the number of inappropriately timed Well Child Care (WCC) visits from 20% to 10%

7. Why Improve Continuity? • AAP and IOM recommend it • Development of a therapeutic alliance: • Patients and parents who trust their physicians are more likely to have better treatment adherence and less likely to have negative health outcomes. Nguyen et al. 2009; Wang and Wu, 2007 • Improved parental perception of care: • A large multi-center, cross-sectional study of resident continuity clinics found that parental scores of satisfaction with care increased with number of visits with a single provider and being able to name the provider. Krugman et al. 2007 • Decreased risk of hospitalizations: • Decreases in continuity of care and poor adherence to the WCC schedule are both independently associated with an increased risk of hospitalizations. Tom et al. 2010

9. PDSA: Cycle 1 • Visited call center. Reviewed primary designation. • Helped change default settings for PFAs at Rangel and at Call Center to better identify areas of interest: Primary, RTC orders. • Didactic sessions with providers detailing the steps necessary to add and/or change the designation of primary.

10. PDSA: Cycle #2 • Reduce the number of undue visits: • Reviewed AAP periodicity schedule with members of the health care team. • Distributed copies of AAP periodicity schedule with call center • Practiced Chart Hygiene • Labeling Eclipsys notes “WCC” • Specific details in the RTC orders (eg. “For WCC in 1 year with Dr. Primary") • Changed RTC order in “Ambulatory Pediatrics Common Order Set” so it can be read without double-clicking

11. PDSA: Cycle 3 • Created and revised a bilingual (English/Spanish) handout for parents to help them understand when and why to schedule appointments • Initial feedback was excellent, parents appreciated the dialogue • Problem: Not used often

12. PDSA: Cycle 4 • Stapled handout to encounter forms • Held didactic session with providers to review the handout and model effective use • Surveyed patients/parents • Surveyed providers

13. Qualitative Measures • Patient Survey • 100% of families found the handout helpful • 80% knew when to return • 40% knew what to do when a form needed to be filled out • 100% knew their PCP • Physician Survey • 75% of providers found the handout at least somewhat helpful and 33% thought it was very helpful. • Only 17% thought completing the handout was too time consuming.

14. Results

15. Conclusions • Improved continuity by improving primary designation and reducing the number of undue or untimely WCC visits. • Did we make effective changes? Or were the changes seasonal? • We haven’t seen the full results of the handout yet as those cycles were completed towards the end of the project. What will happen if we are able to distribute the handout even more widely?

16. Future Directions • Distribute handout to other ACN sites • Include the handout in newborn materials that parents obtain upon discharge from the well-baby nursery. Or staple the handout into yellow card at VC newborn clinic. • Include the AAP periodicity schedule in the training of PFAs in the call center and in the clinics. • Rangel also has the highest no-show rate in the ACN. Did this project help improve the number of patient that do not show?

17. Thanks • Call Center Staff • Rangel PFAs • Rangel Residents • Rangel Attendings • Dr. Berger and Dr. Lane