Family Advisory Group

1. Family Advisory Group A Tool for Enhancing Family Engagement in a Primary Care Pediatric Practice Francie Chalmers, MD FAAP WCAAP Population Health Forum June 8, 2019

2. Single specialty independent pediatric primary care clinic • 9 Medical Providers (5 MD, 3 ARNP, 1 PA, for 6.5 FTE) • 1 Integrated Behavioral Health Provider (LICSW) • Serving Skagit Valley since 1981 • Farming community with patient population that is 60% Medicaid Skagit PediatricsMount Vernon, WA

3. First created in 2003 by Dr. Andrea Lowe, clinic pediatrician who was Skagit County Representative of Washington State Medical Home Network at the time. • Formal way to engage families in enhancing the care and services that the practice provides. • Provides bi-directional support for a patient centered medical home • Advice for administration and medical leadership on family needs and clinic priorities from a family perspective • Help with resources for families Skagit Peds creates its firstParent Advisory Group

4. Previous Support from: • Kate Orville at UW-CHDD • Washington State Medical Home Partnership • Structure of the Group • Dr. Lowe served as Lead and planned and chaired the meetings • 8-10 parent members, including local neurodevelopment center parent support leader and a public health nurse, both with children with complex health care needs. • one clinic admin staff • Diversity goal What happened back in 2003?

5. Parent Survey • Waiting Room information for families • Patient education in video format • Bulletin board – what’s happening in the community • Resource library/Brochures from community support agencies • Supporting Families Discussions at Meetings • Being a parent first, enjoying your child • Transitioning adolescents • Ask a pediatrician night Family Advisory Group Projects

6. Strong work with mutually recognized value for several years • Cost varied with activities but was minimal and covered by the clinic • Refreshments and small financial enticements encouraged participation but bulk of the “work” fell to the Pediatrician Lead. • The arrival of TWINS led to a temporary “hold” on the Group’s activities which lasted nearly a decade. Sustainability Challenges

7. Led to re-learnings about the value of Family Engagement • The Family Advisory Group was re-activated in 2018 • Same pediatrician leader, now with 10 year old twins, arguably no less busy, but eager to try again Skagit Peds embarks on PCMH Certification Journey, 2017

8. Families learn about practice management and optimum ways to communicate their needs with the Practice. • Families are given an opportunity to facilitate change when indicated • Families skilled in navigating care for their child with complex medical needs can share information with those less experienced The Family Advisory Group as a resource for Families

9. Feedback from Parent Surveys • Promote the clinic’s newly integrated Behavioral Health Consultant • Out of the box Product Availability • Parenting books • Medical Supplies • Commonly used medications • Alternative care opportunities • Payment for Triage nurse call in lieu of low complexity health care needs • Weekend and evening hours The Family Advisory Group as a resource for the Clinic

10. Ideal parent member criteria • Have had a child in the Practice for at least a year • Feel comfortable being vocal without being confrontational – positive • Have been proactive in their child’s care in the past • Reflects diversity of patient population, including cultural, ethnic, and socioeconomic diversity • Reflects diversity in age and medical complexity of patients • Consider including an adolescent to participate • Be clear about time commitment and responsibilities Considerations for Membership

11. Previous members’ children have mostly aged out of the practice. • Offered membership to front and back office staff. Chose 1 of each. • Used EHR report to identify patients with chronic disease diagnoses • Providers asked to review report and highlight parents they think would be interested and positive. • Reviewed shortened list at an office meeting and chose 8 people to invite to participate. • Providers also asked to “nominate” diverse variety of families. • Opportunity would have been posted in Waiting Room but quickly filled spots by methods above. Recruiting Members

12. Pediatrician lead – Dr. Andrea Lowe • 2 Clinic Staff members • Billing • Nursing/Triage • 6 parents • Clinical Diversity • Social/Cultural/Ethnic Diversity New Parent Advisory Group at Skagit Pediatrics

13. Schedule for 60-90 minutes and be respectful of members time • Typically after patient hours, consider if have means to provide child care or reimbursement • Provide refreshments and small stipend (we pay $40/meeting) • Provide Agenda, ideally sent out ahead of time by email • Consider call-in or ZOOM option for participation Meeting Planning

14. First Meeting • Discussed concept of Family Advisory Council • HIPAA Training and consents signed • Toured Clinic • Began brainstorming project ideas Second Meeting • One month later – to maintain momentum • Continued to brainstorm ideas for clinic staff to review at next office meeting • Decided to start with family satisfaction survey Enticements • Food: staff rotate bringing treats to the meetings • Cash: team members receive $40 per meeting for their time Meeting Schedule and Enticements

15. Share experiences, peer support opportunities • Identify specific practice issues or concerns and brain-storm solutions • Discuss projects that can make the practice more patient-centered and family-centered • Provide related input on clinic operations, practice facilities, services offered, communication between staff, clinicians, and families. • Provide input concerning youth transition to adult medical care • Raise awareness of opportunities for peer support for families whose children share similar chronic conditions Expanded Role of the Family Advisory Group

16. Location: • Waiting Room • Practice Website • Social Media Content might include: • Calendar/Posters with Community Resources, meetings, and Programs • Brochures from/Links to Community Resource Agencies • Seasonal programs and events information related to the Practice and the Community Educational/Community Information

17. Pre-visit questionnaire • Patient/Family Satisfaction Surveys • Solution for friendly appointment reminder systems • Signage in the waiting room to protect sick children • Explanation of ideal use of Practice Portal for information sharing, forms completion, communication Additional Family Engagement Support Projects

18. Questions? Thank You

19. Human Centered Design Beth Harvey, MD, FAAP

20. CMS meeting experience • Human centered focus- parent family engagement • A desire to try something novel and different and bring some creativity to work. Why I’m interested in Human Centered Design

21. Understand the concept of human centered design • Learn about a 5 day design sprint • See an example of in pediatric practice that our clinic tried to address with human centered design By the end of the presentation, you will be able to:

22. It is a practical, repeatable approach to arriving at innovative solutions • Start with inspiration • Move to Ideation • Then Implementation • Ideo has some good web resources at https://designkit.org What is Human Centered Design?

23. A 5 day design sprint was designed by Jane Knapp at Google • https://GV.com Monday: map out the problem and pick a place to focus Tuesday: sketch competing solutions on paper Wednesday: make difficult decisions and turn your ideas into testable hypotheses Thursday: design your prototype Friday: test it with real people What is a Design Sprint?

24. We tested the theory that you could virtually do a design sprint using experts in other states through digital connections. • This was led by a partnership with Mathematica who studied the process, and Wowza who led the team sponsored by CMS. • https://wowzamade.com/site/ What was different about our sprint?

25. Walk through the office from parking lot to how people walk and drive to your office. Take pictures to share with offsite staff. • Give an overview of the practice, processes, environment, people, costs and resources that impact the issue. Pre work

26. What is the issue that you want to address? • We picked patient wait times and experience. • How many patients do you see in a day, what are their ages, now do they typically wait? • How many providers and nurses/MAs work during the day? • How many patients leave on a busy day? • How often does the practice run behind? • How long do patients expect to wait? • What do they do while they wait? • How many people come with more than one child or other family members? Overview

27. How do patients make appointments? • What are they told about waiting? Is there consistent messaging? • Can you map the process from the appointment to leaving the clinic? • What have you tried before? Processes

28. Describe and document the environment: • parking lot • public transit stations • building entrances and corridors • waiting areas • Furniture • things to do while they wait • décor, include sounds, music etc. Environment

29. What are the people like who tend to get impatient and leave? • Are there common traits among the people who are more or less patient? People

30. How much money does this problem cost? • What resources besides money are available to address the problem? • How much money would be available to attempt to solve or reduce the problem? Cost/Resources

32. Pediatric Associates WA • Beth Harvey MD • Wendy Fairall ARNP DNP • Jennifer Bavley-Thomas RN • Alanna Loeb RN • Amy Clark MA • Cindy Strandberg manager • Wowza • Jeff Rabkin MN • Ed Prentiss KY • Amy Vandereau TX Design Team

33. Train the Doer The goal is to have designer- coaches work alongside the project team, doing, demonstrating and teaching new skills that the project team can learn and deploy in future quality improvement projects. • Virtual Coaching The designer coaches work remotely with the project team using web based tools to address the design challenge. • 5 Day Design Sprint Working from prep work the week before the entire design work is completed in a week. Design Approach

34. Tools • Google Hangouts • RealtimeBoard • Remote subject matter experts • Adolescent with chronic health needs • Parent of a child with special health care needs • Queuing expert Virtual Design

36. Pediatric Associates sees over 100 patients and day • wait times can extend beyond 10 minutes sometimes. When unexpected things happen patients can wait over an hour and sometimes staff have to stay over 2 hours after closing to finish up work. Patients may forgo care at our office and go to urgent care or walk out. • Pediatric Associates wanted to find practical solutions to reduce wait times and to making waiting a better experience for patients. • A medical practice is a very busy operation with urgent needs filling every day. • Finding time in a busy practice to solve problems and collaborate to explore solutions to make the practice run better is nearly impossible. Design Challenge

38. Have a goal • Starting with a clear goal so that focuses the work so that we can accomplish valuable work in 5 days.

39. A user centered journey map with sprint questions and “how might we” questions provides the constraints needed for innovative user centered solutions. Develop a Journey Map

48. Design sprint prompted improvements in book program • Mrs. Pockets Kids Entertained while dad fills out paperwork Create a Prototype

49. Test your prototype Card prototypes were used. Receptionist gives out the cards at checkin

50. Waiting Time Cards: Kids Cards that occupy kids and create subtle reminders to doctors on appointment times