Improving Care and Outcomes of High Risk Newborns

Improving Care and Outcomes of High Risk Newborns after NICU Discharge using the Patient Care Navigation Program Ma Teresa C Ambat, MD Region 15 RHP Meeting El Paso First Healthplan, 1145 Westmoreland Drive September 24, 2014 1: 00 pm

Description of the Project o Establish a Patient Care Navigation Program within the High Risk Clinic, a neonatal follow‐up program at Texas Tech University Health Sciences Center (TTUHSC) El Paso ‐ Department of Pediatrics o Patient navigation ‐ a process by which an individual (a patient navigator) guides patients through and around barriers in the complex care system to help ensure that patients receive coordinated, timely, and site‐appropriate health care services o Target infants born at < 32 weeks gestational age and/or infants whose birth weight was < 1500 grams – a cohort of high‐risk patients discharged from the El Paso Children’s Hospital (EPCH) – Neonatal Intensive Care Unit (NICU)

Patient Care Navigation Strategic Plans Road map to navigate toward success Steps Timeline Step 1: Analyze the role of the patient navigator Step 2: Identify Our Existing Strengths August – December 2013 Completed Step 3: Identify Our Challenges August 2013 – DY 5 (2015) Ongoing process as new challenges surface during the implementation of the project. Step 4: Develop the Bones of Our Navigation Program August – October 2013 Step 5: Develop Outreach Plans to Enroll Patients and Promote Retention DY 3 (May 2014) – DY 5 Basic structure for implementation of the program has been completed. Subject to modification as needed in adherence to quality improvement process. Ongoing process. New strategies will be implemented as they are identified. Ongoing process Step 6: Initiate the Navigator Role Step 7: Growing Our Patient Navigation Program DY 3 – DY 5 Goals for DY 5 Status

Project Milestones and Metrics – DY 3 P 2. 1: Number of People Trained as Patient Navigators Goal: 1 Additional Patient Person hired – start date 8/20 Navigator hired and trained P 2. 2: Develop Outreach Plan to enroll patients in Navigation Program Goal: Complete Patient Outreach Plan P‐ 10. 1: (Customized) Report on Goal: Complete report on types of services provided to those services provided to high risk patients enrolled in High Risk Patients the program Completed and submitted 8/7 Care navigation services form created in EMR at Texas Tech Clinic (June). Navigators use the EMR form to document the services given to enrolled patients (started in June). IT support uses an identifier to track this form to generate the report.

Outreach Plans to Enroll Patients and Promote Retention • Patient navigator will arrange meetings with families of patients enrolled in the program and establish relationship prior to NICU discharge. • Provide information on High Risk Clinic Follow up program to help families understand importance of follow‐up programs and its impact on long‐term outcomes to encourage compliance. • Promote patient navigation as a process/service that will help ensure that patient’s receive culturally competent care that is also confidential, respectful, compassionate and mindful of patient’s safety. • Patient navigators will participate in the discharge process at EPCH – NICU and help NICU team prepare families for the next phase of care. • Conduct follow‐up phone calls 2 weeks after NICU discharge and after each High Risk Clinic visits. • Phone call reminders prior to High Risk Clinic visit.

Outreach Plans to Enroll Patients and Promote Retention • Provide arrangements for transportation to and from High Risk Clinic appointment. • Address and accommodate for other barriers (daycare, work schedule, health insurance etc. ) that keep patients from keeping their follow‐up appointments. • Provide incentives to promote compliance with follow‐up such as age appropriate toys and books for every follow‐up visit kept. • Educate the community about our High Risk Clinic Follow‐up program and our new navigation program by meeting with community providers. • Leave flyers at Pediatric offices in the city to encourage follow‐up. • Hire and train an additional patient navigator to provide services to accommodate the increasing number of patients enrolled in the program.

Navigation Services June July August September Total 16 154 93 63 297 Care Coordination – High Risk Clinic 1 12 5 5 23 Care Coordination – PCP 1 14 9 1 25 System navigation – DME issues 1 6 10 12 29 Apnea monitoring 1 20 11 12 44 Phone calls – prior to High Risk clinic visit 0 27 23 9 59 Total Services Top 5 services Other services: care coordination for subspecialty ff‐up, barriers to access, education on appropriate use of services, insurance services, phone calls – 2 weeks after NICU discharge, prescriptions, social services, home health, referrals to ECI and other rehab facility, triage medical problems, etc.

Project Milestones and Metrics – DY 3 P‐ 8. 1: Participate in semi‐annual face‐ to‐face meetings or seminars organized by the RHP Goal: Participate in at least two (2) face‐to‐face meetings /seminars 1 st meeting: 7/30 2 nd meeting: 9/24 I‐ 10. 2: Increase Number of Unique Patients served by Navigator Program Goal: 30 patients (QPI) (Compliance with first High Risk Clinic appointment) 50 – QPI as of 9/16 (Total number of target patients recruited for DY 3 = 74) Request to change QPI for DY 4 and DY 5 – submitted in August I‐ 10. 2: Increase Number of Unique Patients served by Navigator Program – DY 4 Goal: 55 patients (QPI) I‐ 10. 2: Increase Number of Unique Patients served by Navigator Program – DY 5 Goal: 60 patients (QPI)

Category 3 Measures IT 8. 21. Developmental screening in the first 3 years of life. • • • Indicator: The percentage of children who had screening for risk of developmental, behavioral and social delays using a standardized screening tool documented by 12 months of age. Denominator: Target patients who turn 12 months of age between Jan – Dec of measurement year. Targeted patients: Premature infants enrolled in the program (< 32 weeks and or birth weight < 1500 grams). Communication and Symbolic Behavior Scales Developmental Profile (CSBS‐DP) – performed during high risk clinic visit on target patients (<32 weeks and or < 1500 g) starting at 9 months chronologic age (started in June). CSBS‐DP screening is incorporated in EMR – High Risk Clinic visit form for documentation and tracking. • Total number of targeted patients who turned 12 months from January to September of measurement year 19 • Dropped out before 9 months 6 • Total number of targeted patients developmental screening using CSBS‐DP who received 6/13 = 46% (4 patients had CSBS‐DP at 12‐ 13 months, not counted)

Category 3 Measures IT 9. 9. Transition record with specified elements received by discharged patients. • Measure: Percentage of patients who received transition record at the time of discharge. • Targeted condition – Premature infants < 34 weeks admitted and discharged at El Paso Children’s Hospital – NICU must have documentation of receipt of transition record. • Transition record entered as an event by residents/NNPs at discharge (started in June). Tracking done monthly. Total patients Discharged < 34 weeks GA Oct Nov Dec Jan Feb Mar Apr 3 11 15 7 5 10 3 May 8 Patients with documented receipt of transition record (%) Jun Jul Aug Sep Total 9 12 9 Pend 92 4 11 9 Pend 24 44% 92% 100% Pend 26%

Category 3 Measures IT 8. 25. Sudden Infant Death Syndrome Counseling • • • Measure: Percentage of children 6 months of age who had documented Sudden Infant Death Syndrome (SIDS) counseling. Numerator: Children who had documented SIDS counseling within 4 weeks of birth or by first pediatric visit, whichever comes first. Denominator: Children who turned 6 months of age during the measurement year. Targeted facility. All infants discharged from the El Paso Children’s Hospital – NICU. SIDS counseling incorporated in discharge teaching on all infants discharged from the El Paso Children’s Hospital – NICU. SIDS counseling is entered as an event in Site of Care by residents/NNPs for documentation (tracking started in June). Total patients discharged from EPCH-NICU Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sept Total 101 97 87 72 69 99 64 78 87 99 102 Pend 955 49 91 90 Pend 230 56% 92% 88% Pend 24% Number of patients who received SIDS counseling (%) Baseline data of 0% will be reported in September (None of those patients who received SIDS counseling from June onwards had turned 6 months. The above data will be included in the next reporting period in April).

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