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ASTHMA QI: FOLLOW-UP AND TRANSITIONS OF CARE. Washington Heights Family Health Center 181 st Street. AIM STATEMENT. To increase by 25% over baseline the number of follow-up visits within one month of an asthma exacerbation in the ED or clinic in patients 4-18 years of age. SECONDARY GOALS:.

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slide1

ASTHMA QI:FOLLOW-UP AND TRANSITIONS OF CARE

Washington Heights Family Health Center

181st Street

aim statement
AIM STATEMENT
  • To increase by 25% over baseline the number of follow-up visits within one month of an asthma exacerbation in the ED or clinic in patients 4-18 years of age.
slide3

SECONDARY GOALS:

To educate 100% of providers about asthma follow up guidelines

To notify 100% of providers via SHM when their patient is seen in the ED for an asthma exacerbation

Schedule 75% of patients with an asthma exacerbation for a follow-up appointment with their primary resident/attending team

return visit guidelines for patients with asthma
RETURN VISIT GUIDELINES FOR PATIENTS WITH ASTHMA
  • Changes made to medication
    • in 2-6 weeks to ensure that asthma control is maintained
  • No changes made to medication
    • in 1-6 months
  • After an exacerbation
    • within 1-4 weeks
    • contact the provider by phone within 3-5 days

Busse et. al. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma—Summary Report 2007. J Allergy Clin Immunol 2007; 120;5 S95-S138.

Fanta, Christopher H. An overview of Asthma Management. UpToDate, August 2013.

Lasley, Mary V. Adherence to Follow-up Recommendations in Asthma. Pediatrics 2008; 122;S211; DOI: 10.1542/peds.2008-2139LLL.

state of the union chart review
STATE OF THE UNION: CHART REVIEW
  • 4-18 year olds with asthma, seen in the ER and diagnosed with an asthma exacerbation (or receiving steroids or albuterol) between 7/1/2012 and 6/30/2013
  • Patient discharge instructions reviewed for any follow-up date or interval
  • n=137, 94 unique patients
  • no follow up date provided: 37.2%
  • follow date provided: 62.8%
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“follow up with your doctor in 1-2 days”

“see your regular doctor by tomorrow at the latest”

“go to your regular clinic on Monday”

“follow up with your PMD – call for appointment”

“see your doctor in 2 to 3 days if not improved”

“See Dr. Coelho at 181st street clinic on Tuesday, October 8th for a walk-in visit”

EXAMPLES OF FOLLOW-UP INSTRUCTIONS

pdsa cycle 1 provider education

PDSA CYCLE 2: INVOLVING THE PFAS

  • A list was generated daily of the ED asthma discharges. It was given to PFAs to schedule patients with f/u visits within 2-3 days vs. 1-2 wks
  • 1/26/14 to 2/8/14, N=8
  • FOLLOW UP: 4(50%) [3 in 3-5 days, 1 in 6 days]
  • 2/9/14 to 2/22/14, N=4
    • FOLLOW UP: 2(50%) [2 in 1-2 weeks; 1 >2wks]
PDSA CYCLE 1: PROVIDER EDUCATION
  • patients admitted to ED in 12/13 & 12/14, after presentations given
    • Total ED Visits: 17
    • % of ED visits w/ clinic F/U: 41.2%
pdsa cycle 3 patient care manager
PDSA CYCLE 3: PATIENT CARE MANAGER
  • In March 2014, a Pediatric Care Manager (PCM) joined the team at WHFHC to help coordinate care for patients with chronic conditions including asthma. Her role was to actively identify asthma patients, reach out to families and confirm appointments.
  • Chart review: 3/2/14 to 3/19/14
  • N=3
  • Follow-up visits within 1 month: 2 patients (66%)
  • After PMD and patient care manager reached out to no show patient – 100% follow up at 1.5 month
slide9

RUN CHART FOR QI PROJECT

n = 17

n = 8

n = 3

n = 137

slide10

BARRIERS TO FOLLOW UP REPORTED BY PATIENTS

  • "My child was much better after being seen in the ED which is why we didn't come",
  • "My child's asthma was stable and responded well to treatment, we had a follow up appointment in March already (3 months out)“
  • "He was sick in December and we went to the PMD in March“
  • "I was busy with work, grandma was unavailable to help"
  • "I followed up my child's asthma right after at the Allergy clinic already".
  • all patients contacted reports that at some stage of their visit, someone has reinforced the idea to them that their child should be seen by the PMD for asthma follow up
future directions
FUTURE DIRECTIONS:

Expand and recruit full-time or part-time PCMs in other clinics for improved asthma follow-up visits

Have PICs review weekly asthma list discussed in weekly Medical Home meeting

Generate automatic follow-up visits once visit in the ED coded for “asthma” or “asthma exacerbation”

Increase asthma action plan distribution during follow up visit, an opportunity to discuss actions in “yellow” zone

thanks to everyone at the 181st clinic

Attendings

Steve Caddle

Melanie Gissen

Melissa Glassman

Adriana Matiz

Dodi Meyer

Kim Noble

Noe Romo

Minna Saslaw

Dana Sirota

Residents

Edna Akoto

Serine Avagyan

Oliver Barry

Julia Brown

Daniel Coelho

Andy Geneslaw

Laura Kurek

Priya Jain

Divya Lakhaney

Natasha Li

Regina Myers

Shannon Nees

Monica Prieto

Ava Satnick

Emily Skoda

Zoya Treyster

Daniel Yu

Sam Zhao

THANKS TO EVERYONE AT THE 181ST CLINIC!

And special thank you to

Lucille Lebovitz, NP and Joselina Goris!

PFAs

Cindy Ferrer

Omari Levers

Ivelisse Rodriguez

Jasmin Morris-Pena

Lelanie Vinales

RNs

Joan Mahoney

Basilia Abdel-Glei

Joanne Gordon

Gerthy Michel

MAs

Aurora Gomez

Karina Guzman

Petra Ortiz

Candida Rodriguez