Belvis Pediatric Clinic The NYC Health + Hospitals / Lincoln and NYC Health + Hospitals/ Belvis service area encompasses many neighborhoods that the federal Health Resources and Services Administration (HRSA) has identified as being medically underserved and/or or having a shortage of health providers Belvis Pediatric Clinic at a Glance -5 Pediatric Providers -Clinic Visits in January, February, March 2017: 12,150
Belvis Pediatric Clinic Team Project Team Lead Erica Gilbert- Dir. Population Health Contact: Erica.gilbert@nychhc.org; 718-579-1774 Clinical Asthma Champion: Leslie Joyner, MD Team Members: Reemberto Perez, RN- Supervising Nurse Gifty Amankwah, RN- Asst. Director of Nursing Peggy Hyman- Public Health Educator Maria Vega- Community Liaison Worker Matilda Concepcion, RN- Nursing (not pictured) Christopher Perdomo- Clerical Assistant (not pictured)
Belvis Pediatric Clinic Timeline September 2016 Guideline Utilization training for entire Pediatric Clinic Team. Identification of asthma care team and clinical champions. Establish method of clinical data collection. January 2017 February 2017 Shift focus to Asthma Action Plan for PDSA cycles. Identify patients referred to specialty asthma care. Monitor high utilizers. April 2016 August 2016 Project Team recruitment. RESPIRAR Staff met with Belvis Administration to map our plan of action and looked at initial clinical data. October 2016-December 2016 PDSA cycles begin, identifying the ACT and Asthma Control documentation as an area of concentration due to asthma guidelines focus on CONTROL. Immediate implementation of ACT into daily asthma care. March 2017 May 2017 Shift focus to environmental trigger evaluation and education. Conduct Asthma Awareness Day at Belvis. Integration of asthma project with DSRIP Home Visit Program (3dii).
Belvis Pediatric Clinic Asthma Patient Flow Key Roles: PCA- responsible for providing patient with proper ACT (ACT or cact/ English or Spanish) Provider- Reviews ACT and incorporates into control assessment; provides AAP to parent/child when they need an update; provide appropriate specialty care referral Pre-Visit Planning- identifies when patient needs new or updated AAP
Our Project Aim (from September 2017) From August 2016 to April 2017, the Belvis Pediatric Clinic will improve asthma control and reduce the burden of asthma in the South Bronx with a goal of increasing utilization of Asthma Action Plans (AAPs) and Asthma Control Tests (ACTs) to 70% and reducing the total number of ED visits and hospitalizations. How We Measured Up 100.00% Asthma Care Measure in Belvis Pediatric Clinic, August 2016 - April 2017 80.00% 60.00% 40.00% 20.00% 0.00% August September October November December January February March April severity control ACT AAP ICS
How We Measured Up The focus of the Belvis Team s clinical improvement project was the: 100% Asthma Control Test (ACT), and Asthma Action Plan (AAP) Focal point of PDSA cycles ACT and AAP From Then to Now ACT: 0% in Sept 64% in April 80% AAP: 40% in Sept 70% in April 60% 40% 20% Factors to consider: Adjusting criteria as we went along (no ACT under 4 y/o) 0% Aug Sep Oct Nov Dec Jan Feb Mar Apr ACT AAP ACT hard copies vs. Scanned into the EMR (human err.) AAPs from other settings
How We Measured Up 100% 80% 60% 40% 20% While the focus of the Belvis Team s clinical improvement project was the ACT and AAP the other measures were continuously monitored, including: Severity Classification Control Classification ICS Prescription Factors to Consider: Severity, Control, and ICS The ACT proved to be a significantly useful tool to aid in control classification Protocol on documentation of patients who s asthma is managed by a Pulmonologist/Allergist Resistance on various levels Many young patients (under 4) 0% Aug Sep Oct Nov Dec Jan Feb Mar Apr severity control ICS
How We Measured Up Health Outcomes Simply tracking the outcome data was beneficial as the team was able to identify high utilizers of the ED as well as hospitalizations Because Lincoln and Belvis share an EMR 1.4 1.2 1 0.8 0.6 0.4 0.2 0 ED visits and Hospitalizations 1.23 0.90 0.90 0.80 0.73 0.45 0.45 0.40 0.40 0.10 0.10 0.13 0.15 0.05 0.05 0.07 0.03 0.00 Aug Sep Oct Nov Dec Jan Feb Mar Apr ED Hosp Other factors to consider: Seasonality- Typically in the Bronx March ranks as the highest volume of ED patients seen for asthma Started incorporating Belvis Asthma Room Logs half way through
How We Measured Up There are various factors we needed to consider when looking back at our data: Increasing sample size Aug-Oct: 10 ; Nov-Jan: 20; Feb-April: 30 Increasing scrutiny to originally unconsidered factors ex) Asthma Action Plans completed vs. reviewed ex) ACTs when asthma is not the primary visit reason Staff Turnover, Resistance on multiple levels What s Next? PDSA on trigger evaluation and education Incorporation of new NYS Asthma Action Plan
Patient Interview- History Very young male Latino child (<1 year old at first visit) Mother is Primary Care Giver; family members with history of asthma Mom would bring in baby whenever he had any coughing or difficulty breathing resulting in From October 2016 - March 2017 2 Emergency Room Visits 5 Urgent Care Visits 1 Hospitalization <5 Follow up Clinic Visits Mother was distressed about continuous coughing, didn t understand when to give medicines, was confused because -she, her husband, and 6-year old daughter- don t have asthma. Patient recruited in Belvis Clinic Asthma Room Patient recruitment was fortuitous because Belvis Asthma Room
Patient Interview- Post Op Recruited during first follow up after treatment changed in early May Recruited at the right time for a few reasons Mother provided AAP and ICS at this visit Provided additional education following treatment change Mother provided clear teach-back on AAP, device technique Home environment discussed, trigger exposure discussed Patient Interview reinforced that: Clinical Team provides Asthma Action Plan to mother Mother felt that asthma team explained treatment plan clearly and feels more confident using different medicines More robust comprehension about ED utilization vs. Clinic Care Surprises/Future Considerations Mother still seems in denial about child s asthma diagnosis Mother considers non-medical advice and common misconceptions Reinforces low literacy level of certain patients Still room for improvement- Health Outcomes impr. may take months-years
Belvis Pediatric Clinic Nurse Reemberto Perez: Staff Testimonials Overall the staff is more aware about what an asthma patient needs to know when they leave the clinicwhether its what medicines need to be taken or what triggers a patient s asthma, we make sure they know when they walk out the door Project Lead, Erica Gilbert: I do believe that all would say that it s been a good experience, albeit sometimes a bit frustrating, trying to get all staff on board at the same time. But especially with the ACT, we were basically at 0 percent compliance and we have improved dramatically in the past six months Health Educator, Peggy Hyman: I have seen a lot more patients in the asthma room as opposed to making that visit to the Emergency Room We want to empower them to take care of their asthma Clinical Champion, Dr. Joyner: The ACT has helped many of our physicians. They praise it as being an asset to help in their assessment The program has had a positive impact because as a team we are collaborating to educate our patients to control their asthma with medications, technique, triggers
Belvis Pediatric Clinic: Next Steps Early identification of high risk patients Working with MCOs and DSRIP Integrate new AAP Continuing training- AEC for staff PARENT ENGAGEMENT- parenting 101 MAJOR BARRIERS Not implemented into EMR Time constraints, turnover MAJOR SUCCESSES Linking to DSRIP; linking to Specialty Care Incorporating asthma room log, individual successes
Belvis Pediatric Clinic Questions For any teams not incorporating the asthma care measures into an EMR System are you able to see and track the progress of your improvement? Have you also collaborated/integrated into DSRIP Asthma Programs? Has it been smooth? Has your project had any significant progress working with an MCOs? How so? If you are an Emergency Department Program please ask us about our ED Program- High Utilizer Identification integrated into the Medicaid Accelerated exchange (MAX) Series
Belvis Clinic s Asthma Fun Day!