In the fall of 2013, the Tennessee Chapter of the American Academy of Pediatrics (TNAPP) launched a bold new initiative to address pediatric quality issues in primary care through the formation of the Pediatric Healthcare Improvement Initiative for Tennessee (PHiiT). Following a successful first pilot program in East Tennessee, PHiiT is now expanding its education and quality improvement efforts across the state.
The collaborative – which is inclusive of all Tennessee parties utilizing pediatric care, delivering pediatric care, measuring outcomes or structuring payment systems – came about as a result of conversations with key stakeholders over the course of several years. Allen Coffman, Jr., MD, FAAP, who serves as medical director of PHiiT, said many practices were struggling in the wake of the recession. At the same time, practices were being asked to revamp many of their processes.
“All of this was coming at one time,” said Coffman, a practicing pediatrician with Highland Pediatrics in Chattanooga and past president of TNAPP. “Providers were overwhelmed with the financial changes, care delivery changes, and changes on how our board certification processes were happening … so we asked, ‘How can we do this better?’”
As discussions became more formalized, Coffman said TNAPP realized it would take a broad coalition to address the changes providers faced and drive quality to improve the health of the state’s youngest citizens. PHiiT’s main goals are:
to educate providers about high value process changes for practices to impact serious population health concerns,
to bring together stakeholders to organize and prioritize what those population health priorities are and develop measures to assess outcomes, and
to ensure providers and patients have the tools they need to be successful.
“We’re really focusing on that patient-provider space and making sure the patient and provider have the tools they need to make that a better working relationship,” Coffman said. After all, he continued, “The only ones who can really change healthcare delivery are providers in concert with patients.”
Working with the National Improvement Partnership Network out of the University of Vermont, PHiiT set about to develop and implement quality improvement projects around pediatric health concerns that are high cost, consistent with state and federal priorities, have poor outcomes, are difficult for patients, and/or cause frustration for practitioners. Coffman said each quality improvement project also includes a Continuing Medical Education component and standardization of metrics and outcomes reporting so the collaborative could analyze data and broadly share information and best practices.
The first initiative – Breastfeeding Sustainment and Smoking Cessation Project – was piloted through practices in Chattanooga, Knoxville and Oak Ridge with funding from the Tennessee Department of Health and data support from the Tennessee Initiative for Perinatal Quality Care (TIPQC). Coffman said the project kicked off in the summer of 2014 and winds up this month. An educational program was hosted over two weekends to get providers – which included physicians, nurses, nurse practitioners, and medical students – up to speed on ways to extend breastfeeding and discourage tobacco use around infants, and preliminary data has been very encouraging.
“When you look at breastfeeding, one-third will breastfeed no matter what you do, one-third won’t no matter what, and one-third in the middle are undecided, ambivalent,” Coffman said. “There is a high value window during the newborn period. We know the sooner you get them (mothers) in and the better you engage them that first two weeks, you maximize the chance they will continue to breastfeed,” he explained, adding this newborn period is also the most motivated time for caregivers to quit smoking.
“We have been able to improve the frequency of patients seen within 72 hours of hospital discharge from 31 percent at baseline to 85 percent at our first follow-up,” Coffman said. “Our two-month breastfeeding rate has increased from 56 percent at baseline, which was better than anyone expected, to 62 percent at our first follow-up,” he continued. Coffman did note the higher-than-normal baseline breastfeeding rate could be attributed to the type of practices that participated in in the pilot, which were already working to engage parents around the importance of breastfeeding.
As for the second part of the project, Coffman noted, “Only 60 percent of newborns were being screened for tobacco exposure at baseline. We were able to increase that to three-quarters, 76 percent, at our first follow-up.” He added that instead of just asking if the child was exposed to tobacco, which Coffman said could feel judgmental and garner a biased response, PHiiT trained providers to reframe the conversation. “What we tried to teach was to positively engage the family around their care network and then go back and ask if each of those persons used tobacco.”
Ultimately, Coffman noted, providers need effective tools they can use to engage with patients. “We know there is a finite amount of time that the provider and patient have so we look for the high value propositions … what really works.” He continued, “We really push our education faculty to choose what are high value changes and then communicate that to providers and patients in a way that is useful.”
Coffman said an important part of the equation that has been missing is feedback as to what is sustainable and then using that feedback to help develop payment structures that incentivize continued process improvement. While the information is critical to inform practice and impact outcomes, Coffman was quick to say that PHiiT provides tools and data but allows providers the freedom to be innovative in how they address issues with patients.
With the first pilot successfully drawing to a close, PHiiT is looking to expand that project and others across the state. The collaborative recently announced an award of a $1.49 million, three-year contract with the Bureau of TennCare to take PHiiT’s efforts statewide.
The next project is to develop a pediatric metric dashboard with the assistance of all four pediatric residency programs in Tennessee. PHiiT’s quality coach will assist participating practices in gathering data pertaining to the measurement of the metrics. “That will give practices ongoing feedback as to what their practice is doing compared to the state aggregate,” Coffman said of the dashboard, known as the Provider Best Practice Resource.
From there, specific quality improvement projects will be added. Coffman said asthma would be among the first initiatives with obesity, behavioral health and developmental screening modules as other likely candidates to roll out in the near future.
“What we’re hoping is to give practices real data to make business decisions around investing in quality improvement,” he said. “I think providers are going to learn a lot about the way they deliver care.”
PHiiT has begun enrolling additional practices to participate in the expanded programming. Coffman said pediatric, family and general practices that see children are all welcome to participate. In addition, school-based clinics, health department clinics and federally qualified health centers are also encouraged to enroll. For more information, contact Becky Brumley via email at becky.brumley@tnaap.org.
RELATED LINKS:
PHiiT Information at TNAAP: tnaap.org/phiit
TPCA, United Health Foundation Connect for Quality
Last month United Health Foundation awarded $900,000 to the Tennessee Primary Care Association to help support “Tennessee Quality Connect,” a clinical initiative connecting healthcare professionals and patients through Community Health Centers (CHCs) in person or by utilizing telehealth technology.
CHCs, which are often located in communities where primary healthcare providers and hospitals are not easily accessible, serve as a primary source of care for one in 17 Tennesseans. However, when a patient’s condition requires the attention of a physician not on staff at a CHC, a range of barriers from a lack of transportation to not having adequate childcare to not being able to take time off work can stand in the way of seeing the specialist. The United Health Foundation grant is focused specifically on providing access to behavioral health and nutritional counseling services for individuals with hypertension, diabetes and depression to help combat these chronic issues.
The ability to leverage telehealth technology extends the reach of urban-based specialty care providers, improving access to critical health services in remote and underserved areas. More than 10 million people nationwide directly benefited from using telemedicine last year, according to the American Telemedicine Association.
“The Tennessee Primary Care Association’s work in the community has shown significant success in connecting people with quality healthcare services, and we are grateful for the opportunity to support its efforts to bring new, innovative approaches to healthcare,” said Rita Johnson-Mills, CEO of UnitedHealthcare Community Plan of Tennessee.
Announced at Neighborhood Health in Nashville, the grant is part of United Health Foundation’s “Helping Build Healthier Communities.” The funds will be awarded over three years and will support the Tennessee Quality Connect initiative at 17 CHCs, which collectively represent 104 health center sites serving more than 300,000 residents across 44 counties.