Oklahoma Chapter of the American College of Physicians Virtual Meeting 2020

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Browsing Oklahoma Chapter of the American College of Physicians Virtual Meeting 2020 by Author "Corbett, Audrey"

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    Improving Outpatient Follow-Up After Hospitalization
    (2020-10) McGinn, Addison; Hurst, Caleb; Blasdel, Jacob; Bordelon, Brian; Abdelmonem, Ahmed; Sharwani, Fahad; Lesselroth, Blake; Cerqueira, Oliver; Corbett, Audrey
    Introduction: Hospital readmission is costly, in both patient quality of life and healthcare expenditures. Timely post-discharge follow-up has shown to reduce preventable readmissions. Efforts should be aimed at improving coordination of follow-ups. The aim of this quality improvement project was to increase post-hospital discharge follow-up by 20% for academic primary care patients admitted to a local tertiary care hospital by June 2020. This QI project was conducted at St. John Medical Center and the OU Internal Medicine Clinic utilizing Plan-Do-Study-Act methodology (PDSA). Patients admitted to OU inpatient teams who also designated OU Internal Medicine as their PCP were included in the study. An EMR query was utilized to measure follow-ups completed within 14 days of discharge. A process map was made, showing intervention points. Gap Analysis/Scatter Diagram was used to show points of largest impact. Methods: PDSA #1: Senior residents were given access to AllScripts (the clinic EMR scheduling program) to directly schedule patient follow-up appointments within 14 days of discharge. Follow-up appointments were included in patients’ discharge paperwork.    PDSA #2: Prior to discharge, patients were screened by care managers for a follow-up home visit. If appropriate, a multidisciplinary team of providers conducted an onsite follow-up visit within 14 days of discharge. Results: After PDSA #1: Residents surveyed after the first PDSA cycle admitted feeling overwhelmed with additional tasks and inconsistently scheduled appointments in AllScripts. In addition, EMR review demonstrated a high no-show rate for patients with follow-up appointments. Due to these results, we sought alternative options. After PDSA #2: Three patients were visited in their homes for an onsite 14-day follow-up appointment. Unfortunately, this process was put on hold given the COVID outbreak. At baseline, 31.6% of patients discharged from the hospital attended post-discharge follow-up visit within 14 days. This percentage declined to 29.2% after our interventions. Conclusion: The low rate of hospital discharge appointments within two weeks of discharge indicates that many patients are lacking crucial follow-up care. This project found that having residents enter appointments directly into AllScripts and performing home visits within 14 days of discharge made no difference in the overall rate of successful post-discharge follow-up visits. Weaknesses of this study include but are not limited to the gap of data between July 2019 and March 2020 and the small number of home visits that were performed. This project confirms the concern that unless new approaches to significant post-discharge follow-up barriers are considered, increasing the percentage of successful follow-up appointments will remain a difficult task.
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    Improving Utilization of an Internal Medicine Clinic Patient Portal: A Quality Improvement Project
    (2020-10) Street, Mark; Jack, Stuart; Drake, Kory; Yarnall, Ryan; Singh, Amritanshu; Vaughn, Kaleb; Gusman, Lindsey; Mullins, Gina; Minton, Vicki; Beasley, Brent; Corbett, Audrey
    Background: The University of Oklahoma-Tulsa Internal Medicine Clinic utilizes an electronic patient portal to improve communication and help achieve the healthcare triple aim of reducing costs, enhancing patient experience, and improving health. Our prior quality improvement initiative successfully improved patient portal enrollment and utilization. Our goal for the continued project was to increase the use of secure portal messaging and decrease the patient call-to-visit ratio. The clinic averages ~1800 visits per month and receives ~3.3 calls per visit with each call averaging ~10 minutes, resulting in significant use of clinic resources. Specifically, our aim was to increase utilization of portal secure messaging (both patient to provider and patient to clinical staff) by 10% and decrease patient call-to-visit ratio by 10% by June 2020. Methods: To effect and measure changes, the Plan-Do-Study-Act (PDSA) model was used. Three PDSA cycles were planned and implemented, as well as one unexpected PDSA cycle. The monthly number of secure portal messages and patient call-to-visit ratios (total number of calls to the clinic divided by the number of visits) were measured. These data points were plotted on XmR charts to determine significant trends and averages. PDSA #1: Laminated flyers containing instructions for portal registration were placed at the check-in desk. PDSA #2: Resident physicians were educated in utilizing the portal for communication with patients. PDSA #3: Information about enrolling and portal utilization were included at the top of the clinical visit summary document. PDSA #4: The widespread medical and social effects of COVID-19 began to affect our clinic. Results: After the first three PDSA cycles, our clinic's average call-to-visit ratio decreased 14% (from 3.37 to 2.89). Patient-to-provider messaging increased 27.3% (from 86.6 to 119 messages/month) and patient-to-clinic messaging increased by 38% (from 104.8 to 170.1). Of the planned PDSA cycles, advertising with flyers appeared to have the greatest change. By March and April, COVID-19 resulted in increased messages to clinical staff and a significant increase in the call-to-visit ratio--likely from the drastic decrease of in-person clinic appointments and increased calls to the clinic. Conclusion: Data prior to COVID-19 showed that portal utilization improved through education of medical staff and basic marketing approaches incorporated into the clinical workflow. COVID-19 was an industry disruptor that both demonstrated the need for enhanced clinical communication, but also affected our prior in-person PDSA cycles. Additional data regarding clinical time spent answering portal messages and effectiveness of portal communication will need to be collected. Increased portal utilization can continue to help with improvements in healthcare cost, quality, and effectiveness--and hopefully continued PDSA cycles can aid in developing new strategies to effectively communicate with our patients during this unprecedented time.
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    Increasing Colon Cancer Screening in the OU-Tulsa Internal Medicine Outpatient Clinic
    (2020-10) Harris, Audrey; Quaye, Eugene; Tran, Elizabeth; Smith, Tristan; Eslam, Mohammed; Albin, Dru; Corbett, Audrey; Sullins, Lindy
    Introduction: Colorectal cancer is the fourth most common cancer and the second leading cause of cancer death in North America. Annually, approximately 53,000 people die of colorectal cancer, yet it is largely preventable through screening. Our quality improvement initiative was to attempt to increase colon cancer screening in United States Preventative Services Task Force (USPSTF) eligible patients in the OU IM clinic by 10% by April 2020. Methods: All patients seen in the OU Internal Medicine clinic were screened for eligibility of colon cancer screening using the USPSTF criteria. If the patients were found to be eligible they were offered several screening possibilities to include colonoscopy, FIT testing, and cologuard screening. The necessary means to undergo testing was then arranged for the individual patient in order to attempt to increase the amount of colon cancer screening by 10% by April 30, 2020. Several PDSA cycles were planned but unfortunately, with the onset of the SARS- CoV2 pandemic only one was able to be implemented throughout the year. The first PDSA cycle consisted of drafting a standardized letter which was added to the clinic EMR that would allow patients to bring a guest with them via SoonerRide to their colonoscopy appointment. Lack of appropriate support to appointments had been a barrier to patient’s ability to keep their screening appointment. The clinic providers and nurses were educated on how to locate and complete the letter. Results: The patient population studied included all eligible adults for colon cancer screening, as defined by the USPSTF guidelines, at the OU Tulsa Internal Medicine clinic. Our data showed that following the implementation of the first PDSA cycle the percentage of patients out of total qualifying patients in the OU IM clinic who have documented colon cancer screening done or had reason why deferred remained at 65.1%. There were no significant increases or decreases in the total percentage. Following the onset of COVID-19 pandemic, the percentage decreased to as low as 62.7%. Conclusion: There was neither a significant increase or decrease in colon cancer screening in the five months following implementation of the first PDSA cycle. However, in March 2020 the American Cancer society recommended that all routine (non-diagnostic) cancer screenings be suspended in the wake of the COVID-19 pandemic. As a result, screening rates decreased by 86% relative to the average before January 2020. Going forward, a focus on FIT like testing may be beneficial during these times to reduce rates of missed cancers.
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    PDSA Cycles Increase Screening for Smoking Cessation
    (2020-10) Abdelmonem, Ahmed; Baab, Kelsey; Cerqueira, Oliver; Corbett, Audrey
    Introduction: Smoking represents the leading cause of preventable disease, disability and death in the United States, disproportionately affecting lower-income populations1. Smoking cessation has been shown to reduce the associated health risks and to lead to a decrease in early mortality. Due to the significant impact of smoking on our patient population, the students at OU’s student-run, free clinic, Bedlam Clinic, decided to implement a series of Plan-Do-Study-Act (PDSA) cycles to address this issue. PDSA cycles are widely used for quality improvement in healthcare systems and have been shown to improve outcomes2. Our aim was to improve tobacco screening and counseling in OU Bedlam student-run clinic by 20% by June 2020. Methods: From September 2019-May 2020, teams of third-year medical students, PA students, nursing students, social work students, and faculty attendings implemented PDSA rapid improvement cycles. The goal was to increase smoking screening and cessation education above the current baseline of 49.4% by the end of the year. Each individual team created a plan, which they implemented in the clinic. The number of screenings, counseling sessions, and smoking cessations were recorded per team. The teams met bi-monthly to discuss and improve upon the plan. By the third PDSA cycle, the entire clinic agreed to implement the protocol of the team with the largest increase in tobacco screenings. The protocol chosen involved an interdisciplinary approach: the nursing student initiated the screen, the Medical/PA student provided counseling for those interested, and the social work student provided resources for those motivated to quit smoking. Results: At the first PDSA cycle, 49.4% of eligible patients at Bedlam Clinic had a tobacco screening completed, with an upper and lower confidence level of 53.6% and 45.1%. Monthly data points following the initial PDSA cycle were consistently above average. By July, 2020, after 4 PDSA cycles, the average tobacco screening rose from 49.4% to 59.8%. Conclusion: Implementing a multidisciplinary, quality improvement project to increase smoking cessation screening at the OU Bedlam student-run clinic was successful. Tobacco screening at the Bedlam Clinic improved by 20.1% from its baseline. The PDSA cycles elucidated that documentation of the tobacco screening process was being recorded incorrectly in the EMR. Once this was established, we implemented a protocol ensuring that this important step was not forgotten. Specifically, nursing students documented the screening in the EMR at the beginning of the visit. This step was implemented across the entire clinic by February 2020, significantly improving tobacco screenings. This project demonstrates that a student-led, annual, QI project using simple rapid cycle improvement leads to improved patient care. These projects should continue to be implemented at the Bedlam Clinic and further expanded to the remaining OU clinics.