2. Disclosure I have no relevant financial relationships with the manufacturers of any commercial products and/or provider of commercial services discussed in this CME activity. I do not intend to discuss an unapproved/investigative use of a commercial product/device in their presentation.

3. Altamonte Pediatric Associates 3 offices in central FL Altamonte Springs, Lake Mary, Apopka 6 MDs, 6 NPs Our Core Improvement Team: Phyllis Zissman – Office Manager Corie Opdyke – ARNP Jaime Candelori – MD Jennifer Roberts – Care Coordinator Tammy Hadley – Parent Partner

5. Aim Statement By March 2012, our practice aims to improve our medical home by focusing on potential ways to improve our processes for providing comprehensive and coordinated care for our patients. 1. Identify the primary care provider for 90% of patients with complex medical needs, and educate the staff so that these patients are scheduled and roomed with their PCP and allotted the appropriate amount of time for the visit. 2. Create, update and discuss with the parent the patient's medical summary and, if necessary, the comprehensive care plan for 90% of all patients. 3. Improve processes that will allow us to systematically track, follow-up and document test results, vaccinations, referrals and schedule appointments to discuss findings with parents and patients if indicated.

6. Saturday appointments established for many years newborns, sick visits, main office only Evening hours established a few years ago parent survey completed to assess need at various times sick visits, main office only as need increased, added extra appointments Same Day Appointments almost half of all appointments are sick visits nurse triage line Enhancing Access to Care

7. 24/7 coverage Nurse/MD on call, protocols established Sunday visits MD will often see patients if needed Facebook/Website/Email patients can access general information electronically Email is occasionally used Enhancing Access to Care

8. But In a practice where we all share all the patients, and we rotate to different offices, how do we improve access to a specific care provider team?

9. Improving Access to Care - GOALS Create Patient Registry – 4 levels Focus on our most complex patients, labeled level 4 Establish PCP team for Level 4 patients Establish Care Coordinator A contact person who gathers information and whose main purpose is to help our most complicated patients Expand Medical Summary into Comprehensive Care Plan A copy to chart and a copy to parents

10. Changing our Workflow Initially, 12 complex (level 4) patients identified Appointments made, introduced to the project Chart color (RED) was a visual indicator Level designated in chart and in computer – all visits double slotted After 3 months, most of the visits were scheduled Sick visits harder to schedule with requested PCP (providers are in different offices on different days, some work evenings or PT) More patients needed Level 4 status More providers would need to be designated as PCP Extending the project to all providers and all offices Continuously adding Level 4 patients to our registry

11. Results to Date Added referral info to PE cards

12. Reflection – initial concerns Changes would result in slower workflow anticipating extended visits with more complicated patients allows us to schedule the extra time we need Nurses know to divert other patient traffic elsewhere when needed Scheduling difficulty How to get patients with their preferred provider MDs have individual templates, but NPs schedule generic Still working out the kinks, but vast improvement

13. Reflection – success and challenges Reciprocal Appreciation Patients, parents and families appreciate our efforts Care Plan in chart and in hand Establishing a PCP team (a work in progress) Having a dedicated Care Coordinator We have discovered their strengths Coordination and organization Some even bring their own “care plan” to us! Challenges - The “Business” Side How to effectively bill for our efforts Educating patients to avoid urgent care centers, retail based clinics, ERs

14. Reflection ACCESS SPECIFIC PROVIDER

15. Remember…. SURVEY PARENTS ABOUT THEIR PREFERENCES Early morning vs. lunch vs. evening hours INFORM PARENTS OF ANY CHANGES use follow up visits from urgent cares or ERs to educate update website, facebook, etc. CONTINUE TO REEVALUATE need for additional appointments and providers? can the patient be seen by their requested provider?

16. Our next steps… Implement parent survey Prefer Access vs. PCP? Sick vs. well? What more can we offer our complex patients? Continue to expand project Satellite offices Patient Registry Improve our tracking systems Referrals Labs, Imaging, etc.