Cicero Health Center of Cook County Medical Home Quality Improvement Team Summary/Highlights of QI Team March 2013

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1 Cicero Health Center of Cook County Medical Home Quality Improvement Team Summary/Highlights of QI Team March 2013 Team Members Building Medical Homes for the Ambulatory and Community Health Network (ACHN) of Cook County, Illinois Program Anne Jacobson, MD, Lead Physician Michelle Floyd-Rebollo, MD Valerie Evelyn, Nurse Manager Noemy Godina, RN Margarita Fuentes, Administrative Leader Michelle De la Torre, Health Advocate Maritza Rosado, Clerk Gabriella Ramirez, Parent Partner Patty Katsuleus, Parent Partner Tammy Jackson-Taylor, DSCC Care Coordinator Norma Mercado, DSCC Coordinator Aide Annie Boesen, ICAAP Donna Scherer, Facilitator, DSCC Accomplishments since LS2: Overall Successes 1. QI Team Meetings - Cicero Medical Home Quality Improvement (QI) Team began monthly meetings in March 2012, and has held 10 meetings. Two parent partners participate in the team meetings sporadically however they continue to offer valuable input. The parent partners have been instrumental in helping to identify clinic issues that present as barriers to the delivery of quality health care. To encourage their continued participation, staff call and remind the parent partners one day prior to scheduled team meetings. 2. Patient Registry - Cicero staff have reviewed and added/removed children either missed or duplicated on the initial report and are adding to this list by recall and as they see families for appointments. Tracking is currently on an Excel spreadsheet. Dr. Jacobson has organized the data into separate reports by Diagnosis. 3. Care Plan Development - Dr. Floyd reviewed the care plan, with staff, and implemented a PDSA test of completing the care plan with one parent. Based upon the positive feedback from the one parent, the team will consider how to proceed with expanding care plan development. 4. Access - The team has been discussing the need to provide more information to families about how to access the clinic and how best to arrange for needed services. Staff feel that many patients come in to be seen when their issues could have been handled over the phone. The Medical Home Family Index results validate this perception; the goal is to develop informational materials to help families better understand how to access the clinic services they need. 1

2 5. Community Partners - DSCC staff from the Chicago North Regional Office, Tammy Jackson-Taylor and Norma Mercado, have joined the team and are regularly attending meetings. DSCC staff are also arranging to meet with families on a monthly basis to help them with the application process and care coordination needs. Plans are to have the DSCC Care Coordinator provide an inservice on the DSCC Program so that all clinic staff have a better understanding of the programs and can refer families who may benefit from the services available. 6. Developmental Screening Project Staff have identified a screening coordinator in the clinic (Michelle) for EI referrals and Noemy has devised a reminder system for the nursing staff to give out the ASQ's at the appropriate developmental ages. While the system overall is waiting for an "ASQ" field to be built into Cerner, the providers have been instructed to record their ASQ scores in the physical exam section of the pediatric note. Additionally, we met with the local EI staff to determine how best to facilitate referrals and documentation of EI follow up. 7. Medical Home Family Index Report the team reviewed the report at the March 11 th meeting and began discussing opportunities for improvement. They are considering expanding use of the Asthma Action Plan because they serve a large number of children with asthma. They are also continuing to discuss developing informational brochures and posters to help inform families about how to better access needed care. Dr. Jacobson plans to contact administration to see if the PCMH brochure being developed has been pilot tested yet; if not, then the team will move forward in developing one for Cicero families. Project Challenges Previously identified challenges continue to include: 1. Engaging parent partners 2. Lack of a care coordinator 3. Inability of nursing staff to access care plans 4. Difficulty trying to implement change in our clinic which is part of a much larger system, not allowing for as much flexibility. 2

3 Cottage Grove Health Center of Cook County Medical Home Quality Improvement Team Summary/Highlights of QI Team March 2013 Team Members Building Medical Homes for the Ambulatory and Community Health Network (ACHN) of Cook County, Illinois Program Tais Crawford, MD, Lead Physician Kimberly Walton-Verner, MD Jodie Bargeron, ICAAP Facilitator Dru O Rourke, ICAAP Facilitator 1. Accomplishments since LS2: a. Asthma Action plans continued successfully, now in state of maintenance b. Implemented procedures for identifying patients due for developmental screening 2. Challenges and Successes Challenges: Nurse Uveeda Cade moved to different clinic, staff and QI team members reduced Successes: Strengthened existing relationship with CFC during developmental screening initiative, very positive meeting 3. Utilizing findings from family surveys Dr. Verner reviewed in February and identified ways to recruit parent partners to address barriers to accessing community resources. 4. Engaging Parent Partners Dr. Verner continues to invite parent partners to participate in the monthly meetings. No regular parent partner yet identified. 5. Working with patient lists: The asthma patient list is fully developed. Team looking for ways to update and maintain list as new patients enter system 3

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5 Fantus Health Center of Cook County Medical Home Quality Improvement Team Summary/Highlights of QI Team March 2013 Building Medical Homes for the Ambulatory and Community Health Network (ACHN) of Cook County, Illinois Program Name Role on Team Judy Neafsey, MD Pediatrician Jay Mayefsky, MD, MPH Pediatrician Mita Patel, MD Pediatrician Alisa Seo-Lee, MD Pediatrician Eugenia Sta Maria, RN, MSN Nurse Dianna Dosie Nurse Marie DiGiacomo, RN, Nurse Ava Thomas, RN DSCC Care Coordinator Joslyn Jelinek, MSW Social Worker (recently transferred) Tokay Gaines, MSW Social Worker (new member 3/13) Linda Jackson Parent Partner Sarah Zavallah Front Desk (new member 3/13) Kathy Sanabria QI Team Facilitator 1. Accomplishments Since Learning Session #2 (10/10/12) a. As of 3/13/13, the Fantus QI Team has met together 13 times (not including Learning Session #1 on 4/25/12 and Learning Session #2 on 10/10/12). b. At the 11/14/12 QI Team meeting, welcomed Developmental Screening Coach Cherie Estrada and incorporated her onto the Fantus QI Team for support with the implementation of the Developmental Screening Pilot work. c. At the 12/12/12 QI Team meeting Cherie Estrada coordinated an outreach meeting with Child and Family Connections (CFC) #9 office staff members serving Chicago Central/West, including Grace Ortiz, CFC Manager; Monica Patruck, Service Coordinator; and Tanya Wilcox, Parent Liaison. Key Fantus Quality Assurance staff were also in attendance including Irene Marks and Doris Kelly. The team and guests discussed administration of the ASQ-3, Early Intervention referral protocols and procedures, and ways to enhance communication and coordination. d. At the 12/12/12 QI Team meeting, confirmed with the QI Team members their progress on completing the EDOPC online training modules. Many of the Fantus team members made significant progress. e. On 1/7/13, ICAAP hosted the ACHN Project Webinar, where the Developmental Screening Pilot and steps for using the Learning Management System (LMS) for data reporting was held. Dr. Mayefsky has been helpful with reviewing and revising the data reporting instructions and obtaining well-child visit patient lists by clinic and provider for the sites. f. Dr. Mayefsky is working with the CCHHS HIT team to have developmental screening data points added to the Cerner EMR as well as being able to include the ASQ-3 scores. 5

6 g. At the 1/9/13 QI Team meeting, the team discussed the 1/7/13 webinar and the upcoming action steps regarding usage of the LMS. h. At the 2/13/13 QI Team meeting, Dr. Neafsey explained that the CCHHS Patient-Centered Medical Home (PCMH) pilot is wrapping up and the work done with the pilot will be rolled out to all of the ACHN sites in the next few months. These efforts will not replace the work of the pediatric MH QI team but will be complementary. The two projects will be synergistic and should help to implement system-wide changes related to using the Medical Home Network Connect portal and working on transitions of care from ED/hospital to medical home. More information about these activities will be presented at Learning Session 3 and to Fantus staff in the near future. i. At the 2/13/13 meeting, the Medical Home Family Index (MHFI) Fantus baseline and aggregate reports were distributed. The Fantus site report was reviewed in its entirety. The aggregate report will be further discussed at the March meeting. j. At the 2/13/13 meeting it was learned that Ms. Jelinek is being transferred to another clinic. The current social worker assigned to the pediatric clinic is Ms. Tokay Gaines. She has been invited to join the team. Also, it was suggested that a clinic reception front-desk staff member be invited to participate. Accordingly, Sarah Zavalla has also been invited to attend future meetings. 2. Overall Successes and Challenges Successes The Fantus QI Team continues to work together to embrace the ongoing process of the Plan-Do-Study-Act (PDSA) cycle of Medical Home Quality Improvement. The team remains engaged and motivated and meets consistently every month. Nursing staff and residents have been trained on the procedures related to the developmental screening QI activitiy. Dr. Mayefsky has requested that HIT staff add a place for the ASQ-3 score to the intake area of the EMR. Section 6 of the Standardized Illinois EI Referral Form, Authorization to Release Information, has been translated into Spanish so it can be made available to Spanish speaking families. This section of the form was also highlighted to remind providers and staff that parents must complete this section to promote information sharing and enhance communication. The developmental screening QI work has been kicked off and at least one provider from each of the five participating ACHN pediatric clinic sites has entered baseline data. Six providers will be able to receive Maintenance of Certification Part 4 credit via the American Board of Pediatrics. Dr. Laura Deon, a rehabilitation physician from Rush, has been added as a newly approved DSCC provider. Fantus will be able to make referrals to Dr. Deon which will be a great help to patients. This will also serve as a reminder to make sure that complex children that meet DSCC requirements are enrolled into the state program. Linda Jackson, parent partner, was invited to serve as a parent representative for a DSCC state conference in Springfield, IL in March Challenges Joslyn Jelinek, key team member and social worker for Fantus pediatrics, has been assigned to another clinic within the ACHN. A new social worker, Tokay Gaines, will be taking over responsibility for interfacing with the CFCs for the pediatric clinic and coordinating and making referrals to EI, faxing over the referral to the CFC, recording the referral in the tracking log, and following up with the parents by phone to encourage them to complete the EI referral. Omar will continue to do this for the high-risk NICU clinic. The team looks forward to working with Tokay. Dr. Neafsey has announced her retirement from the ACHN CCHHS effective March 22, Since she has been the lead champion for medical home QI efforts for the pediatric ACHN sites her leadership skills 6

7 will be greatly missed. Dr. Neafsey advises that she plans to stay involved with the system QI work on a volunteer basis and will continue to serve as the lead pediatrician on the Maternal and Child Health Bureau funded ACHN Medical Home innovative models grant through August Utilizing Findings from the Medical Home Family Index (MHFI) a. Fantus gained participation of 12 families out of 25 to complete the MHFI. The team reviewed the Fantus baseline MHFI report at the February 2013 meeting and is reviewing the ACHN aggregate report at its March 2013 meeting. The team identified 1) reducing patient/family wait times in the clinic; 2) helping patients better understand how to access clinic staff during and after office hours; and 3) providing better access to same-day visit appointments. All of these remain challenges that will require more intense focus by the team. 4. Engaging Parent Partners a. Fantus QI Team has benefited from the dedicated presence of Linda Jackson, parent partner, at nearly every QI team meeting (with the exception of 3 meetings due to illness) it has held over the past three years. Linda has encouraged the team to identify one or two more parent partners to join the team, preferably a Spanish speaking parent. b. Linda Jackson is attending two future QI team meetings at the four other ACHN pediatric clinics: Cottage Grove, Vista, Logan Square and Cicero to help organize and engage parent partners. Linda will mentor parents who have recently joined medical home teams. The facilitators have provided Linda with their meeting schedules so she can attend two of their team meetings in the near future. 5. Working with Patient Lists a. Fantus has not done much with the chronic condition patient lists generated for fielding the family surveys at baseline. 6. Engaging Community Partners a. Ava Thomas, DSCC service coordinator, regularly attends the Fantus QI team meetings and has been a helpful contributor and resource to the Fantus team in helping to identify communitybased services and supports. 7

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9 Logan Square Health Center of Cook County Medical Home Quality Improvement Team Summary/highlights of QI Team March 2013 Team Members Building Medical Homes for the Ambulatory and Community Health Network (ACHN) of Cook County, Illinois Program Denise Cunill, MD, Lead Physician Miriam Calvache, RN Matilde Torres, social worker Candida Flores-Matheu, nurse coordinator Maria Pena, Administrator Rosa Rangel, parent partner Myrna Gutierrez, parent partner Myrtis Barnes, DSCC Care Coordinator, Chicago North Regional Office Jeanine Solinski, ICAAP Rita Klemm, Facilitator, DSCC 1. Accomplishments since LS2: Developmental Screening has been our main focus. Logan Square initiated the Developmental Screening process right after the last Learning Session. There have been 12 referrals to Early Intervention since the tracking of screening began with excellent follow-up. Creating PCMH teams, identifying the roles in patient care, and improving communication among team members. Logan Square is participating in the Patient-Centered Medical Home (PCMH) initiative for Cook County HHS along with the Medical Home Network and will be starting depression screening on adult patients with diabetes. 2. Challenges and Successes Challenges: Developing new workflows and addressing the needs of the PCMH teams with limited staffing resources (which is slowly improving) but yet continuing forward with new changes within the system as a whole and at a clinic level. Successes: Logan Square had a very positive meeting with the local CFC. The 36 hour f/up call has been successful, however the practice is losing the Social Worker who makes these calls. Since so many families at Logan Square are Spanish speaking, we were able to suggest that the Standardized Referral form be translated into Spanish, and the permission section where families sign has been translated for more informed consent. Logan Square is finalizing details for access to the EMR portal with St Mary's hospital/resurrection Health Network in order to review progress notes from ER visits and diagnostics as part of continuous 9

10 continuity of care. Additionally, we are working to share pictures of the providers with the surrounding ERs to help identify the PCPs. Our perseverance to continue onward and adapt to the changes despite obstacles and to learn how to rely on our team members for help and guidance...compromise! 3. Utilizing findings from family surveys as a team, Logan Square has not had the opportunity to discuss these findings. As the facilitator reviewing this summary, it is very positive that families feel heard, feel staff explain things clearly to both patients and families, and feel staff know their overall health needs and concerns for their child s health. Over 75% of families indicated that they have always been satisfied with the services received. With discussion about a brochure template, creating a brochure for the practice that lists options for access to care after-hours and access to review medical records along with promoting the practice as the medical home seems like a good first step. Enhancing care coordination and educating families about care coordination is another potential activity. 4. Engaging Parent Partners Logan Square has 2 parent partners that meet regularly with the team. Their participation helps to keep them well informed with changes in our PCMH and they offer input on the new practice processes. As mentioned in our last summary, the need for Spanish translation has made participation more difficult for one of the parents. 5. Working with patient lists: The patient list of CSHCN in Cerner is building. Other providers are giving her the names of children with special needs for the registry. The importance of listing all chronic condition codes has been discussed. Efforts are underway to assure documentation in Cerner for all procedural coding so that IL Health Connect (IHC) is able to know from looking at the billing that various screenings (ASQs and lead) and vaccinations were done. 6. Engaging community partners: Logan Square has been tracking referrals to specialists and has refined the process to streamline the time involved and maximize success in receiving reports. Tracking referrals has helped in obtaining reports in a timely manner and assuring that families get the specialty care appointments needed. Logan Square has been updating a list of specialists and resources to which the practice frequently make referrals, their medical home neighborhood. The overall list is updated as resources are added. Newborn hearing screening audiologists have been added as a referral resource for babies who do not pass the newborn hearing screen. Valuable open communication was established with the local CFC. Logan Square staff were invited to attend the Local Interagency Council, which meets 3 times per year, by the CFC. It is an opportunity to meet staff from other agencies and to share information. For those children aging out of EI, CFC #11 has a liaison with Chicago Public Schools (CPS) in the office to help with the transition to Early Childhood programming. UIC-Specialized Care for Children will be providing an in-service with Logan Square staff members in April

11 Vista Health Center of Cook County Medical Home Quality Improvement Team Summary/Highlights of QI Team March 2013 Building Medical Homes for the Ambulatory and Community Health Network (ACHN) of Cook County, Illinois Program Vista QI Team Members Name Role on Team Dr. Swati Bhobe Pediatrician Megan Kane Towle Physician Assistant Victor Medina Clinic Administrator Edith Castro RN (CN II) Raquel Perez Medical Assistant Maribel Reyes Clerk V Cherie Estrada Developmental Screening Coach Phyllis Azriel SCC Care Coordinator Sandra Guerrero Roche Parent Partner Stacie Serratos Parent Partner Jon Ashworth QI Team Facilitator 1. Accomplishments Since Learning Session #2 (10/10/12) a. As of 3/8/13, the Vista QI Team has met together 11 times (not including Learning Session #1 on 4/25/12 and Learning Session #2 on 10/10/12). b. At the 11/9/12 QI Team meeting, welcomed Developmental Screening Coach Cherie Estrada and incorporated her onto the Vista QI Team, for support with the implementation of the Developmental Screening Pilot work. c. At the 12/14/12 QI Team meeting, met with Brenda Devito, Program Manager from Child and Family Connections #6, the Early Intervention program that serves most of the Vista patient population. The team discussed referral protocols with Brenda. d. At the 12/14/12 QI Team meeting, confirmed with the QI Team members their progress on the EDOPC online training modules. Many of the Vista team members made significant progress. e. On 1/7/13, several Vista team members participated in the ACHN Project Webinar, where the Developmental Screening Pilot and steps for usage of the Learning Management System (LMS) for documentation of developmental screening data. f. At the 1/11/13 QI Team meeting, the team discussed the 1/7/13 webinar and the upcoming action steps regarding usage of the LMS for documentation of baseline data. g. At the 2/8/13 QI Team meeting, Phyllis Azriel from Specialized Care for Children (SCC) came to share with the team an introduction to SCC and how SCC might be of some assistance/support to some of the children and families at Vista. Phyllis has offered ongoing support. h. At the 3/8/13 QI Team meeting, Edith shared January and February s results of implementation of the ASQ-3 developmental screening for 9, 18, 24, and 30 month old well child visits. Within these age intervals, the number of developmental screenings administered has been increasing significantly. 11

12 2. Overall Successes and Challenges a. Success: An Asthma Educator (Maritza) continues to come to the Vista Clinic on a weekly basis. The educator has switched the day of the week she is coming, in an effort to meet some new families. b. Challenge: Many families continue to have a hard time understanding and/or following through with their child s Asthma Action Plan. c. Success: The Vista QI Team continues to work very well together to embrace the ongoing process of the Plan-Do-Study-Act (PDSA) cycle of Medical Home Quality Improvement. d. Success: The Vista QI Team continues to be in touch with the pediatric staff at Northwest Community Hospital (Arlington Heights), as many of Vista s pediatric patients go to the ER there. e. Success: Vista s vaccination outreach and tracking project has been a very successful application of a PDSA cycle of QI. f. Success: Vista gave more flu shots than any clinic in the system, other than hospital-based clinics. 3. Utilizing Findings from the Medical Home Family Index (MHFI) a. For the Medical Home Family Index, Vista s team set a goal of recruiting 40 families and having 25 of the families follow through to complete the MHFI. In the end, Vista recruited 41 families and had 26 families complete the MHFI. We were very pleased to reach this goal and the team worked hard to see this through. b. 2 points for ongoing QI Team emphasis, based upon family feedback in the MHFI: 1) MHFI Question 1, specifically responding to the statement: Through this clinic, I get the health care that my child needs when we need it (including after office hours, on weekends, or holidays. The QI Team has decided to take some simple steps of more comprehensively reminding parents of the existence of after hours/on call physician availability. 2) MHFI Question 5, specifically the question During the past 12 months, how often have you been satisfied with the services you received at this clinic. The QI Team has decided to take this opportunity together to address some core areas of patient satisfaction during their visit. The team will unpack this more over the next few meetings. After patient visit summaries may be useful, as well as providing simple messages through the clerks. 4. Engaging Parent Partners a. Vista s QI Team has successfully integrated 2 Parent Partners into the team. The Parent Partners are actively involved in the discussions of the team. They are educating themselves about the medical home developments of Vista s practice. And they have a lot of positive input to the team as well. 5. Working with Patient Lists a. Vista has not found the patient lists to be overly helpful yet. b. In the future, Vista would like to access patient lists to drill down on specific information about the patients. For example, with an asthmatic patient, the Vista team may want to drill down on some of the following questions: 1) How many asthmatic patients had their flu shot? 2) How many have been seen at the clinic within the past 3 months? 3) How many have had refills on their Albuterol. 6. Engaging Community Partners 12

13 a. Health Promoters (Promotores de Salud), through Northwest Community Hospital They have an office there in the community center where the Vista Clinic is located. These appear to be mostly for Spanish speaking populations. b. Asthma Educator As mentioned above, she is a resource to both patients and families. c. Specialized Care for Children (SCC) Hopefully, this connection will also help the Vista team to know about resources available within the various communities in which Vista families live. 13