Practice Transformation

I just spent two days in Seattle with a group of awesome pediatricians doing fabulous work to transform their practices. While “Practice Transformation” feels like the next big buzz word, there have been multiple projects funded through Centers for Medicare and Medicaid Innovation Grants around changing care delivery and payment models. Most of them are adult-focused because of the drive to bring down healthcare costs. However, Washington State was one of only two states in the country to specifically put efforts behind innovation of care delivery to children. Among some of the most advanced practices were Office Practicum practices! Kudos to them for being on the cutting edge through the Transforming Clinical Practices Initiative.

If you are among the pediatric practices who has been providing great care by doing “business as usual”, I caution you to pay attention. Care delivery and payment is changing around us and if you don’t pay attention and get involved, you will likely be in a reactionary, defensive position where you can’t guide your own trajectory. What did we talk about at the meeting? Creative ways to change how we approach getting the right care, in the right place, at the right time.

What does this mean? First, you need to have a good understanding of who your patients are. Are they the patients who are marked active on your patient register table or does your staff never change this status when patients move, graduate, or leave the practice? Why does this matter? Because the payers have what they think is an accurate list of the patients who they believe you are responsible for serving. If their list doesn’t match yours, they are likely judging your quality based on inaccurate information. You can’t even begin to address the needs of your patient population if you don’t’ know who they are and as much as possible about them.

Providing the right care means really giving all your patients the benefits of preventive services based on Bright Futures guidelines. Good care and many pediatric quality measures are based on well visits. Are you identifying patients who are overdue for care and contacting them according to their preferred communication method on a regular basis? Ideally, this should be done monthly. If you don’t know how to use these tools, find out and task someone in your office to make this a priority. It also means using evidence-based guidelines where available. Are you still doing ear checks after every acute otitis media? That is no longer recommended unless the child has another risk factor (such as speech delay, hearing loss or recurrent infections.)

Where is the right place to receive care? Are your patients going to the Emergency Department or Retail Based Clinic instead of your office? You can’t begin to tackle that problem unless you know how extensive it is, or ask your patients and families why they went? Do you need to enhance your practice access with weekend hours or better after-hours phone advice and triage? Are your schedules over-filled and you can’t appropriately see the patients who should be seen? Is your scheduling staff sending everyone to the ED on Friday afternoon because they want to leave early?

What is the right time? For chronic disease management, it’s before they end up in the hospital with an asthma exacerbation or at the mental health crisis center due to a suicide gesture. For acute care, you need to ask yourself, are you seeing all kids with colds/coughs who call same day for an appointment? Do they really need to be seen at all? If you bring them all in every day, and they expect a rapid appointment, what happens when your office is closed? Have you reinforced the belief that they need immediate medical attention and head to the ED or Urgent Care?

Asking hard questions and eliminating preconceived notions of “we have always done it this way” is the first place to start on this journey of practice transformation. The AAP has some great resources on their Practice Transformation webpage and is leading the way with the Task Force on Pediatric Practice Change. Stay tuned for more to come.

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