Maya Bunik, MD, MSPH, remembers clearly the day a 3-year-old toddler came to the Child Health Clinic at Children’s Hospital Colorado for an acute visit. After treating him, Dr. Bunik asked his Spanish-speaking mother about his speech. After learning he only spoke a few words, Dr. Bunik had a realization.
“He’d fallen through the cracks,” she said. “His family had been bringing him to clinic when he was sick, yet he hadn’t been seen for any well-visit checkups that would have caught his speech delay.” (Pictured right to left: Dr Christina Suh, Dr. Maya Bunik and Andrea Loasby, Project Administrator)
She and her team connected his mother with a patient navigator. But she knew this wasn’t an isolated case. In fact, the clinic team had already started a conversation about continuity of care.
Well child care is always important. Considering their practice demographics – of the 11,000 patients they see each year, 90% receive Medicaid – she knew they needed to do more for this vulnerable population.
That’s when Dr. Bunik and her colleague, Kelly Galloway, MS, RN, CPN, joined the Institute for Healthcare Quality, Safety and Efficiency (IHQSE) program. Dr. Bunik describes the experience in a single word: Transformative.
“The program connected us to the right resources, such as EHR and data support. Plus it gave us space. We had ½ a day once a week to think outside the box,” she said.
The project they implemented focused on the most concentrated time for well-visits, the first year of a child’s life. Having the ability to pull the right data was a game-changer: They learned that only 25% of patients had presented for all five appointments in the first year.
“These appointments are so important. It made us wonder, how did they miss the memo?”
The first step the IHQSE team took was surveying their families. The results were surprising: Only 6% knew the meaning of the term “medical home.” They also learned that most families wanted to see the same provider at each visit, but this only happened half of the time. And only half of this population came back after the first two visits.
“It was clear we needed to do a better job educating our families about the importance of well care.”
Dr. Bunik and her team developed a multi-pronged campaign to reinforce “The First Five.”
“Primary care is about the relationships that are built when the family establishes care,” said David Keller, MD, vice chair of Clinical Affairs and Clinical Transformation. “The First Five initiative allows providers in our practice to build those relationships during a critical time in the life of the family.”
The timing is so critical that the quality improvement team’s first act was sending a clinic representative to the maternity unit at University of Colorado Hospital to talk to families and schedule the first appointment.
They also worked with the marketing department to develop collateral related to a family’s path in the first year of life, which included banners for the waiting room, handouts and a binder with educational materials.
And, at each well care visit, families received an incentive.
“We started by giving out diapers and onsies and a sleep sack,” explained Dr. Bunik. “At the four month appointment, they received a tummy-time mirror, and at six months, a sippy cup.”
But the biggest incentive was given to families who made it to the 100% club of The First Five: a $50 gift card to Wal-Mart.
“That card can buy a lot of diapers,” she said.
Changes were also made within the clinic itself.
First, they added fields to their discharge summary that honed in on the importance of upcoming visits. And they added a feature allowing providers to schedule the family’s next appointment in the exam room.
“The families love it. There’s just something about being in the room and saying, ‘we really want to see you again, so let’s get this scheduled now,’” Dr. Bunik said. “Our providers seem happier with this system as well. They come to work each day, and their patient list is filled with families they know.”
The clinic also began dividing their patients into four panels. With help from providers at AF Williams Family Medicine Center, they incorporated an intense algorithm to divide patients and providers into four “pods.” Each pod was assigned a color. This empanelment strategy also led to reconfiguring their physical space: Each color pod now has its own space facing the office’s center, which they call the fishbowl.
The first cohort in the Orange Pod has gone through their first year, and 84% of patients and families are on track to join the 100% club.
According to Dr. Bunik, everyone seems happy with the new arrangements.
“Right after we launched, for the first time in our clinic’s history, we reached a 94% satisfaction rating,” she said. “Typically our rating hovered around 72%. The rating has fallen since then, but we’re still maintaining ratings in the high 70s and low 80s.”
Dr. Bunik believes that the ratings have improved because of the personalized care patients are getting. “It’s nice to walk into the exam room and not have to retell every aspect of your health story again and again,” she said. “They know the team and the team knows them. It’s a win for them both.”
The clinic team is currently assessing the costs of the incentive program and assessing its effectiveness. They’ve also received funding to expand the First Five program within the other pods, and plan to expand the program to cover the first three years of life.
“We believe that, over time, this will result in better care at lower cost for our children and families,” said Dr. Keller.
They will also be launching a screening that assesses social determinants of health: food insecurity, drugs, violence, mental health issues, etc.
“We estimate that about half of our families have something going on that’s impacting their health. We can’t, of course, solve everything in one visit, but continuity of care is a good place to start,” said Dr. Bunik.
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