Improving Practitioner
Continuity
at Rangel Clinic
Betty Reyes, Taina Sanchez, PFA Staff, Call Center Staff
Evelyn Berger, Hetty Cunningham, Christine Krause, Tawana Winkfield
Elshadey 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
Table 1a: Baseline Data
# 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
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:


Improved parental perception of care:


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
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
100
90
80
% of Patients with
Primary Designated in
EMR
% of Visits With Any
Provider Deemed Undue
or Untimely
% of Appropriate Visits
With Correct PCP
70
60
50
40
30
20
10
0
September
January
April
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