1. Attendings Dr. Kostacos, Dr. Niketakis, Dr. Timko. Dr. Wisler, Dr. Romo, Dr. Potter, Dr. Soren, Dr. Pfeffer, Dr. Catallozzi, Dr. Pethe, Sarah Delaney, Dr. Stockwell, Dr. McCann, Dr. Robbins and Dr. Matiz Residents PGY-3: Cynthia Su, Amy Chirico, Ryan Gise, Nicole McKinnon, Jennifer Rathe PGY-2: Sona Chauhan, Aliza Alter, Allison Baxterback, Eugene Khandros, Elizabeth Seashore, Saira Siddiqui, Roselle Vittorino, Angela Anderson PGY-1: Chelsey Mitchell ‎, Abigail Sage ‎, Julia Emanuel ‎, Esther Berko ‎, Sharon Kook ‎, Christina Welsh ‎, Danielle Fernandes ‎, Candice Maietti ‎, Ellis Rochelson, & Julia Conway Nurses Diana, Ernestina, Estella, Jasmine, Sandra, Vicki, and Adora MAs Stacyann, Jessie, Hasse, Ivette, Carmen, and Marilyn PFAs Kecia, Roxann, Vivian, Yajayra, Yoima, Jennifer, Diana, and Crystal Supervisors Alfred Mancebo, Anderson Mercedes, Kim Moore and Evelyn Bunin at the Call Center Audubon Clinic: Putting the ‘home’ in medical home since 2013 And Focusing on Sustainability and Spread in 2015 Audubon QI Project May 20 th, 2015

2. What is a medical home? “The Medical Home is the model for 21st century primary care, with the goal of addressing and integrating high quality health promotion, acute care and chronic condition management in a planned, coordinated and family-centered manner.”

3. Medical Home: Why and How? Benefits Lower costs Mortality Less hospitalizations Less ER visits Better medication adherence Fewer missed school and work days Factors Primary care provider(s) Seen regularly Relationship Knowledge of chronic patient’s health issues and specialists

4. QI: AIMs AIM #1: Increase the percentage of chronic children being actively transitioned from 40% to 70% by June 2015 AIM #2: Increase the chronic patient documentation in the Children with Special Health Care Needs Section (CSHCN) from 79% to 85% AIM #3: Improve the transition from inpatient to outpatient care

5. Global AIM : AIM Statement Identification of children that have special health care needs Standardization of protocol for transition Identify provider barriers and obtain provider buy in for transition process Identify Patient barriers to transition of care Key Drivers : Intervention s: ACN CLINIC SITE:_______________________________ QUALITY IMPROVEMENT KEY DRIVER DIAGRAM © Diagram Patent Pending– Audubon Clinic IMPROVING QUALITY TRANSTITION OF CARE between providers at year end from graduating PGY- 3s to rising PGY-2s for children with chronic conditions We aim to increase the activity of transitioning children with special healthcare needs from graduating residents to specific rising PGY2s, from 40% (baseline) to 75%, by June 2015. Develop criteria for patients needing transition Assign residents who will follow transitioned patients for the upcoming years Block time for verbal sign-out between residents to facilitate transitioning Trial face to face meeting with select families during regularly scheduled appts with primary resident MD and newly assigned MD prior to graduation Provide updated primary patient list and identify patients for transition Develop an approach to chronic patient chart hygiene Create Transition of Care note in EMR Create Transition of Care letters in English and Spanish for EMR ✔ ✔ ✔ ✔ ✔

6. Primary Provider List

7. Amb Peds Primary Provider Transition of Care Note

8. Sample Transition Letters

10. Survey Results

11. AIM # 2 Chronic Care 2 sections in notes: Patient coordination Classification of illness Goals: Initial  improve use of sections Long-term  use classification to better coordinate care Book high risk appt slots Quarterly CSHCN list Closer follow up for unstable patients

12. AIM #2

13. AIM #3: Appointment Request- ACN/PEDS

14. AIM #3: Post-Hospital Stay PCP/Subspecialty Follow up Orders Month of the Year

15. Final Results Aim #1: The process and measures are still ongoing. We have created a transition of care note in the EMR as well as letters for the families for use at all ACN sites Aim #2: In March, 74% of patients had CSHCN correctly labeled and documented problems in that section Aim #3: Use of the order remained stable over the first four months after its roll out. This information can provide a baseline for further study

16. Future Directions Regular interval reminders Quarterly tracking of CHSCN Documentation Primary Transitions % 3 rd yrs letter; face to face meetings Transition note Patient satisfaction survey Inpatient/outpatient transition order set Automated discharge appointments PGY-3 high risk appt slot Improved PMD notification by SHM of admission

17. Special Thanks to…. Dr. Laura Robbins and Dr. Adriana Matiz Dr. Teresa McCann Evelyn Bunin Dr. Jen Rathe New York State Hospital Medical Home Grant And of Course…

18. Thank you Audubon Family!

19. Now That That Is Done…

20. References American Academy of Pediatrics; Medical Home Initiatives for Children with Special Needs Project Advisory Committee. The Medical Home. Pediatrics 2002; 110(1):184-186. Cooley WC, McAllister JW. Building Medical Homes: Improvement Strategies in Primary Care for Children with Special Health Care Needs. Pediatrics 2004; 113(suppl) 1499-1506. Homer CJ, et al. A review of the evidence for the medical home for children with special health care needs. Pediatrics 2008; 122(4):e922-937. Starfield B, Shi L. The Medical Home, Access to Care, and Insurance: A Review of Evidence. Pediatrics 2004; 113(suppl):1493-1498.