Improving Practitioner Continuity

at Rangel ClinicBetty Reyes, Taina Sanchez, PFA Staff, Call Center Staff

Evelyn Berger, Hetty Cunningham, Christine Krause, Tawana WinkfieldElshadey Bekele, Sandhya Brachio, Kathleen Brennan, Alicia Chang, Jamie Harrington, Jillian Hochfelder, Karen Lee, Tolu Onigbanjo, Laura

Perreta, Pelton Phinizy, Lauren Sanlorenzo, Ronald Zviti

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.

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.

Initial Data Collection

# Patients seen*

# with PCP assigned

% PCP designation

Audubon 984 512 52%Broadway 757 653 86%Rangel 415 267 64%Wash Heights 876 700 80%

Total 3032 2132 70%

* Number of patients discharged from clinic over 20 day period ending 9/29

Table 1a: Baseline Data

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.

AIM Statement Increase the number of scheduled patient

visits with the correct Primary Care Provider (PCP) from 56% to 75% by:1. increasing the percentage of patients with a

designated PCP from 64% to 80% and,2. improving PCP schedule availability by

decreasing the number of inappropriately timed Well Child Care (WCC) visits from 20% to 10%

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

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.

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

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

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

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.

Results

September January April0

102030405060708090

100

% of Patients with Primary Designated in EMR% of Visits With Any Provider Deemed Undue or Untimely% of Appropriate Visits With Correct PCP

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?

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?

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