1. ASTHMA QI: FOLLOW-UP AND TRANSITIONS OF CARE Washington Heights Family Health Center 181 st Street

2. 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. AIM STATEMENT

3. 1)To educate 100% of providers about asthma follow up guidelines 2)To notify 100% of providers via SHM when their patient is seen in the ED for an asthma exacerbation 3)Schedule 75% of patients with an asthma exacerbation for a follow-up appointment with their primary resident/attending team SECONDARY GOALS:

4. 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.

5. 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%

6. “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 181 st street clinic on Tuesday, October 8 th for a walk-in visit” EXAMPLES OF FOLLOW-UP INSTRUCTIONS

7. 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 2: INVOLVING THE PFA S 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]

8. 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

9. n = 17n = 3 n = 137 n = 8 RUN CHART FOR QI PROJECT

10. "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 BARRIERS TO FOLLOW UP REPORTED BY PATIENTS

11. FUTURE DIRECTIONS: 1)Expand and recruit full-time or part-time PCMs in other clinics for improved asthma follow-up visits 2)Have PICs review weekly asthma list discussed in weekly Medical Home meeting 3)Generate automatic follow-up visits once visit in the ED coded for “asthma” or “asthma exacerbation” 2)Increase asthma action plan distribution during follow up visit, an opportunity to discuss actions in “yellow” zone

12. 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 MAs Aurora Gomez Karina Guzman Petra Ortiz Candida Rodriguez And special thank you to Lucille Lebovitz, NP and Joselina Goris! 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 PFAs Cindy Ferrer Omari Levers Ivelisse Rodriguez Jasmin Morris-Pena Lelanie Vinales RNs Joan Mahoney Basilia Abdel-Glei Joanne Gordon Gerthy Michel