Project Option 1.1.4 - Expansion of Pediatric primary care by providing Health Periodicity Exams in conjunction with a visit to an acute care walk in clinic
Unique Project ID:84597603.1.6
Performing Provider Name / TPI TEXAS TECH HS CTR FAMILY MED / 84597603
Goal: The goal of this project is to increase the number of children who receive appropriate health periodicity exams as defined by the AmericanAcademy of Pediatrics Bright Futures Recommendations and are current in their immunization status.
Description: Completion of nationally recommended preventive pediatric health care (Periodicity) examinations in our population is challenging at all age ranges, and particularly after the 12 month visit. A number of reasons may contribute to this including parental perceptions that “everything is all right”, transportation challenges, or the need to take off work and remove the child from school or day care. In addition, a significant number of our patients access care on both sides of the border and may believe that they have received an equivalent service in Juarez. The result is that a significant number of patients with Medicaid funding to cover the entire cost of preventative care do not utilize this service. Instead, they access care on an “as needed” basis through acute care services. Motivating parents and caregivers to access preventative screening examinations services is challenging even when the cost is entirely borne by federal or state programs.
The populations we most commonly serve, Hispanics with low household educational and higher levels of poverty, at are particular risk of not receiving health maintenance exams. [i] Eighty-nine percent of the patients we treat in our after-hours acute care walk in clinic are uninsured, or have Medicaid or CHIP as a payor.
We propose to utilize a “just in time” delivery model to offer periodic health exams visit to all eligible children in the family of an index patient who presents to the walk in clinic. This approach has been successful in a Medicaid population in Oklahoma[ii]. We do not intend to supplant the traditional provider – patient relationship where one exists and the parent is regularly accessing preventative care. Rather we are identifying children who have fallen off the recommended pathway, are not receiving services they are eligible for, and use the acute care visit as opportunity to both provide the screening examination and try to reestablish the patient with a Primary Care Provider for subsequent exams. Re-establishing such a relationship may result in the child receiving future recommended periodicity exams and also reduced use of acute care services in the future.
Challenges: The major barrier will be overcoming parental perceptions that the health maintenance examinations of older children are not important and not worth the time. We propose to overcome this by offering a token incentive (a $10 visa gift card) to the parent for each child including the index patient who completes a due health maintenance examination in conjunction with the acute care visit.
The process milestones chosen for this project reflect the planning, integration with IT and EMR to develop reporting capabilities, and training of staff as well as the development of informational literature, and to establish baseline rates for the improvement targets in this project as well as its associated Category 3 targets. We have chosen a single outcome measure, I- 15.3: Documentation of increased number of unique patients. We define a unique patient as a patient <=18 years of age, who receives a preventative service in the acute care billing area (CPT 99381-99384, 99391-94), and has none of these codes billed in the preceding 6 months. By measuring the number of unique patients, we identify children who are not accessing preventative health care.
Relationship to Regional Goals: This project will address the Region’s goal of overcoming language, socio-economic, and monetary barriers to accessing care as well as enhancing the Region’s ability to provide a continuum of healthcare services.
Expected 5 year Outcome: At the end of DY5, we will have fully integrated well child visits as a service offered to those who seek acute care, and improved the % of patients who are current with recommended periodicity exams and immunization status
Rationale:
Baseline: PaulL.FosterSchool of Medicine Department of Pediatrics provides day, evening and weekend hours walk in acute care services in an effort to reduce inappropriate ED visits in this population. Our proposal is to expand the capabilities of this acute care clinic to provide health maintenance screening, exams and immunizations. This strategy will overcome many of the barriers to completion of these exams in older infants and children: Acute care is a walk-in service; therefore parents are motivated to access care as it is needed. The transportation and work /day challenges have been met through extended hours of availability of services. Acute care services are available weekdays from 8AM to 10PM, and Saturdays from 10AM-4PM. From a cultural perspective, healthcare in our region is a family event. It is not unusual to see two or three siblings in the waiting room with the index patient. This “just in time” strategy presents an opportunity to screen the siblings as well for a needed health maintenance exam, and if necessary, offer it at that point AND connect the parent and child with a primary care provider going forward.
Using data from our largest Medicaid provider, El Paso First, the percentage of children receiving the 12 month well child exam is approximately 43%, and drops to 23% for the 1.5 year exam. Even for younger children, compliance with recommended exam schedules is poor. As a general rule, participation in the first 6 months of life is only in the high 50% range. In older children the participation worsens, falling to the high 30% to low 40% range after one year and is in the teens after age 10. In this scenario, issues such as hearing loss or vision difficulties are frequently not identified until the child enters school and is struggling.
We do not believe the driving issue is access to providers or insurance. The 2010 Paso del Norte Foundation region wide planning symposium addressing and documenting health care needs in a broad area which includes Region 15, and which serves as the basis for our Region’s needs assessment, found no shortage of primary care pediatricians[iii] . Essentially every pediatric patient presenting for scheduled well child care is insured with at least a Medicaid level coverage and we, as well as the overwhelming majority of pediatricians in our region are Medicaid providers.
There is a significant opportunity in our patient population to benefit from this project. Our Alberta based acute care program provides more than 9500 visits / year through daytime, evening and weekend services. A pilot study from April – June 2012 demonstrated that 28% of patients seen were due and eligible for a periodic health Maintenance examination. Of the eligible population, only 14% received the exam in conjunction with the acute care visit, largely related to availability of provider time and / or vision and hearing screening resources. Of the children eligible who did not receive the exam at the time of the acute care visit, less than 5% subsequently returned to receive the recommended examination. Furthermore, eighty percent (80%) of the patients seen through our acute care program are older than 2 years of age, precisely the demographic that does not access routine health maintenance exams. Overall, just applying this program to the index patient provides represents approximately 2600 unique patients. The potential population at risk, and who may benefit from this intervention, is substantially greater, since we were only able to determine need for a periodicity exam on children who were the index patient, not on accompanying family members.
The process we propose is straightforward. Parents of children presenting to the acute care clinic and whose insurer provides a portal for determining the status of their well child visit (all Medicaid and managed Medicaid products), will be informed of the project. If the parent declines participation, the index patient will be seen for their acute care visit as usual. If the parent chooses to participate, we will ask for the demographics of any accompanying children. Staff will query the insurer database and IMTRAC, our state wide, vaccine registry and we will provide all elements of the Healthy Steps Periodicity Exam, including immunizations, hearing and vision screening, as required for that age.
This project has the potential to improve the utilization rates of preventative, health screening and maintenance exams in a population burdened with significant healthcare disparities, as 94% of the patients seen in the acute care program self-identify as Hispanic ethnicity.
Project Components: We chose Project option 1.1.4 as the best description of our proposal. Our proposal represents a unique approach to addressing the challenge of poor use of preventative and screening services in an at risk population.
Community Need: This project addresses the Community Need CN.1, expanding primary care.
Starting Baseline: We will establish a baseline for the number of health maintenance exams done in the acute walk in clinic by tracking data from the last three months of DY2 and annualizing it. This will give us sufficient time to complete Milestone 1, the planning process for the required metrics.
This project represents a significant enhancement to our existing acute care walk-in clinic, and leverages existing space and staff commitments to enhance primary care preventative services.
Related Category 3 outcome measures.
OD-11 Addressing Health Disparities in Minority Populations
IT-11.1 Improvement in Clinical Indicator in identified disparity group. Clinical indicator to be improved and disparity group to be determined by provider (Standalone measure) % of children, who self-report ethnicity as Hispanic, who are current in their immunization status at the completion of receiving a health maintenance examination in the acute care setting.
Up to date vaccination is an essential component of preventative health care for children. It is not unusual to find children who are significantly deficient in vaccinations only identified until they attempt to enroll for school or are hospitalized[iv]. Given the drop off in utilization of health maintenance exams after 15-18 months, this becomes a significant area of potential risk mitigation, and would be addressed by this metric.
Relationship to Other Projects and Measures: This project stands alone with respect to our portfolio of projects, based on a unique need in the pediatric population
Relationship to Other Performing Providers Projects: A number of other providers are addressing the need for increases in primary care and wellness in the region.
Plan for Learning Collaborative We will participate in the RHP sponsored learning collaborative.
Valuation: The Performing Provider considered a series of factors in establishing a valuation for each project. These included the amount of human resources required to meet the milestones of the project, through new hires as well as the assignment of existing support personnel such as Information Technology, EMR and administrative support. We considered what non personnel resources would be required, such as equipment specialized for a certain specialty, and what, if any, additional space would be required to house the initiative. We considered timing issues related to when we had to add resources compared to when a corresponding milestone could be achieved. We also considered the amounts of potential professional fee revenues the project may generate, and offset these against resource demands.
We made a risk assessment for each project, considering the complexity, the scope, the extent to which any single point failure in the milestones would jeopardize downstream success, the degree of inter-dependence on other projects within the waiver program as well as institutional initiatives outside the waiver, and the amount of time required to manage the project. We made an assessment of potential general community benefit.
Finally, we considered organizational priorities, and to what extent the Performing Provider was able to justify partial support of these efforts as meeting existing institutional requirements or objectives.
[i]Lo KM, Fulda KG., Osteopath Med Prim Care. 2008 Dec 8;2:12.
[ii] Smith KD, Merchen E, Turner CD, Vaught C, Fritz T, Mold J.., J Okla State Med Assoc. 2010 Jul;103(7):248-53.
[iii] Paso del Norte Blue Ribbon Committee for a Strategic Health Framework. Phase One: Needs Assessment Report. March 24, 2011. On File.
[iv]Kum-Nji P, James D, Herrod HG., Pediatrics. 1995 Sep;96(3 Pt 1):434-8