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Chapter 5
Redesigning Four Clinical Processes:
Adolescent Preventive Screening,
Pap Smear, Adult Triage, Diabetes
Introduction
An important part of the WVPCA QI project was to provide health center clinical leaders with hands on experience in QI methods and to develop actual Systems Of Care for four severe health problems.
As this project began in June 1997, NRHA formed a five-person coordinating group from its own clinical QI leaders. At the same time, a letter and survey were sent to the Medical Directors and DON’s of all 31 WVPCA member organizations. This letter explained the project and asked for suggestions of clinical topics for SOC development. By the end of August, 17 organizations had responded and voted. These votes were tallied, and four SOC work groups were formed. Each group was assigned a convener from the coordinators’ group. The groups and their conveners were:
- Adolescent Preventive Services (Jennifer Mead)
- Breast and Cervical Cancer (Jennifer Boyd, PA-C)
- Adult Triage (Lynn Legg, RN)
- Diabetes (Dan Doyle, MD).
Out of respect for busy clinic schedules and time constraints, the groups worked mainly by correspondence, individual calls, and conference calls. With guidance from the convener, each group followed a similar work process.
All groups completed the first two steps. There was varying progress on the third, most difficult of the steps. But each group was asked to report and summarize the progress they had made toward a sample SOC for its topic.
The membership, progress, and recommendations of each group is reported in this section.
Adolescent Preventive Screening
1. Problem Statement
Adolescent morbidity and mortality are largely related to health behaviors. Health behaviors learned in childhood and adolescence impact health in adulthood. Adolescents generally do not seek out preventive care services due to cost, lack of transport, lack of awareness, and disinterest. Early identification of health risk behaviors allows for the possibility of intervention by means of education, appropriate referrals, or programs that address frequent or serious needs. The adolescent preventive screening SOC will develop recommendations regarding screening tools and systems that are feasible to implement in primary care centers.
II. Group Membership
III. Process/Chronology
Adolescent preventive screening SOC questionnaires were sent out in late November to individuals who had expressed interest in participating. Phone calls were made to participants who did not return their forms. A summary of participant responses to the questionnaire, as well as sample screening tools, were distributed to group members in late December.
Group members identified the following barriers and possible solutions to providing systematic preventive screening to adolescents:
1. Adolescents don't come for preventive care
2. Brevity of office visits & complexity of issues to be discussed
3. Lack of reimbursement for preventive services
4. No system/plan
The conference call scheduled for January 6 had low attendance. Further development of the adolescent preventive screening SOC occurred in January and February based on individual conversations and work with the Coordinators Group.
IV. Recommendations/Future Priorities
Recommendations:
Issues Still to Be Addressed:
1. Each site needs to consider arrangements to ensure adolescent confidentiality:
2. If sites use written screening, tools (i.e. GAPS), each site needs to decide what to do with screening form: include the form in the chart; include a summary in the chart; offer the adolescent the option of including it in the chart or destroying it (to encourage confidence in the confidentiality of the screening process).
3. Each site needs to develop a list of referral resources and information to use to address risks identified in the screening process. This information will depend on local resources & preferences.
V. Bibliography/References
WV Healthy People 2000.
Kathleen Perkins, MD, and others, "You Won't Know Unless You Ask: The Biopsychosocial Interview for Adolescents," Clinical Pediatrics, Feb. 1997 p 79- 86.
Guidelines for Adolescent Preventive Services (GAPS), developed by the American Medical Association.
Short Screening Questionnaire for Teenagers, developed at the Children's Hospital of Los Angeles.
"Things That Worry Me" questionnaire, from the Children's Hospital of Columbus, Ohio.
"Safe Times Questionnaire/Risk Appraisal" revised version with scoring, scales developed by Howard Schubiner, MD.
VI. Relation to West Virginia HP 2000 goals
Objectives relating to reducing use by adolescents of tobacco products, alcohol, and other drugs; increasing the percent of 10-18-year-olds who have received information on human sexuality; increasing percent of children receiving appropriate identification and follow-up for physical or sexual abuse; reducing youth suicide; and reducing motor vehicle crash deaths in youth.
I. Problem Statement
In 1995 in West Virginia, only 67% of women age 50 and older report having had a mammogram within the past two years. In addition, in 1995 in West Virginia, only 72% of women age 18 and older report having had a PAP test within the past two years. Early detection of breast and cervical cancer significantly saves lives of women. Given the proven effectiveness of screening with careful follow up, we intend to develop a System of Care that will assure full detection, treatment, and education or women at risk for these cancers in primary care centers.
II. Group Membership
III. Process and Chronology
11/97 - 12/97
Members were mailed a "SOC Questionnaire". Members completed this either in writing or during an initial telephone conversation with Jennifer Boyd. See attached summary of SOC Questionnaire, which outlines status of Breast and Cervical Cancer Screening at each site currently.
12/22/97
Conference Call -- See minutes.Group members agreed on standards of care:
1/98
Group members reviewed standards of care with clinical staff at their respective sites. Standards agreed upon by clinical staff at Mercer County Health Department, New River Health Association, Minnie Hamilton Health Center, and Camden on Gauley.
IV. Recommendations
Next steps in development of SOC:
1. Problem Statement
The word "triage" refers to the process by which patients requesting medical care are directed to appropriate care providers according to the acuity and severity of their problems. A well-organized system of patient triage is an important part of quality improvement efforts related to providing patient access for all primary care centers. But many Primary Care Centers find it difficult to reach agreement on a triage system for their practice. Such a system must include defined categories of severity levels and must be guided by the standards required by external payors. The Adult Triage System of Care will be a compilation of tools, techniques and methods for an effective triage system.
II. Group Members
III. Process and Chronology
This QI effort was begun by collecting data from the participants regarding how triage was done in their facilities. This information was compiled in a SOC Planner format and sent to all participants in their SOC binders. In addition, a literature search was done to determine what models of triage systems already existed in other Community Health Centers. This data search revealed that most of the literature is reflective of triage in emergency rooms. Telephone triage systems are also available, but mostly are for purposes of providing advice to patients. Little relevant literature was found that addressed the issue of face-to-face patient triage in community health centers or similar primary care settings.
The Nursing staff of New River Health was polled for input into "drawing a picture" (process diagram) of how triage is done at New River and a flowchart was drafted. Categories used for purposes of this flowchart were Emergent, Non-urgent and Urgent. A Resource list of manuals was also developed for distribution to all participants along with the flow chart example.
Two face-to-face meetings were held with Cindy Hurley R.N. from Rainelle Medical Center to discuss how triage could/should be a RMC. Nurse initiated protocols and the New River Health Walk-in policy were shared with Cindy and all the other participants along with a chapter called Access Mobilization from a book by Dan Doyle, MD on preparing for Managed Care.
IV. Resource List
The Clinical Protocols
Community Health Network Practitioners
Healthnet Community Health Centers and Methodist Hospital of Indiana, Inc.
Triage
Problem Oriented Sorting of Patients
Robert J. Brady Company written by Donald M. Vickery, M.D.
Telephone Triage and Management
A Nursing Process Approach
Written by Reba McGrear/Jo Simms
Telephone Medicine
Training and Triage
A Handbook for Primary Care Health Professionals
Written by Harvey P. Katz, M.D.
Pediatric Telephone Advice
Guidelines for the Health Care Provider on Telephone Triage and Office Management of Common Childhood Symptoms
Written by Barton D. Schmitt, M.D.
V. Progress in SOC development
Some basic information was gained in assisting centers in developing their triage system. An outline guiding how to begin using the tools included in the packet was sent to all participants and emphasized the need to make this a group activity that is specific to each center. Some basic QI information was also included to assist with getting started. The meetings with Cindy Hurley provided some specific information for RMC on how to get the Medical Staff and other parties involved from the beginning. Also, it was found that several of the systems already in place could be considered a part of triage. So, the task may not be creating a system as much as pulling together already existing processes (REDESIGN) into a triage method.
VI. Recommendations
It was recommended in the outline that centers review the triage information, decide what triage system will work best for their facility and develop a plan based on this information. There is great room for imagination and flexibility. The bottom line is that whatever system is used it must assure timely and appropriate access to care for the community and meet the external standards required by the payers, discussion and agreement.
I. Problem Statement
"There is a very high prevalence of diabetes in West Virginia. Many diabetics are poorly controlled with the consequences of excess premature mortality and morbidity such as blindness, amputation, and renal failure. Primary Care practices need a well-organized, systematic approach to diabetes to maintain >75% of patients with A1C < 8.0% and to achieve early detection and treatment of diabetic complications.
II. Work Group Members
Guest Participants
III. Process and Chronology
Based on the responses received from 17 of 31 of the WV PCC’s a SOC work group for Diabetes was established in September 1997. The diabetes SOC questionnaire was mailed to group users on 10/97. The responses from seven centers were tabulated and returned to group members along with a Docs Need SOCs binder in December. This binder also contained the 1998 ADA Standards of Care, a summary of the 1997 Marshall Diabetes Care Study, the "Minimum Technical Standards for Diabetes" from the National Health System of Spain, and an article reporting a successful approach to systematic Diabetes Care (Koperski, M., British Journal of Gen Prac, 1992, 42, 508-511).
The diabetes work group held two conference calls. The first, on Jan. 13, 1998, was attended by 10 persons from six centers.. The second, on Feb. 10, 1998, was attended by 12 persons from seven centers. At both meetings, discussion focused on the current situation, existing clinical guidelines, what is realistic for WV rural primary care, and what our priorities should be.
By the end of the second meeting, the group had reached near-consensus on a broad set of standards for diabetes care. A summary of the group’s conclusions, "Diabetes Care Standards and Priorities," is included here.
While this group has not continued to meet since February 1998, there is optimism that its efforts can continue within the framework of the WV Diabetes Control Program, which recently received a Comprehensive Diabetes Grant from the Centers for Disease Control. Of the seven centers participating in this WVPCA Diabetes Work Group, at least two are targeted as intervention sites within the first year of this program. Hopefully, this number will be increased in the second and third years.
IV. Progress in SOC Development
The main work of the group, after local needs assessment, focused on steps 2 and 3 of the SOC Model, namely selection of standards and agreement on objectives. Step 2 (Standards of Care) was a particular challenge given the respectability of the ADA guidelines despite the fact that many PCP’s view them as unattainable in the short term for many patients who are uninsured and/or living in rural areas. The group studied and discussed the ADA guidelines carefully, coming to near-consensus on a set of recommendations that selectively embraced nearly all of the key elements of the guidelines. The group also took the important next step of prioritizing the areas of basic and continuing patient education, regular lab monitoring, eye care, foot care, and immunizations (Pneumoccal, Influenza, Tetanus).
V. Recommendations and Future Priorities
Front-line primary care clinicians, especially those to underserved populations, should strongly question standards of care that tell us what to do without providing resources or infrastructure to do it, and should advocate for realistic standards linked to programs for meeting them.
WVPCA QI Project
Diabetes Work Group
Final Recommendations for Minimum Standards of Care for Diabetes
Several W.V. Primary Care Centers are working together to improve care and outcomes for diabetic patients. One step is to get agreement on minimum standards of care for diabetes and to set realistic targets for all patients many of whom have limited resources and education.
Participants in The Diabetes Work Group are Dan Doyle, MD (New River), Greg Elkins, MD and Pam Frye, RN, CDE (Lincoln), Rod Fink, DO (Chas - Beckley), Mike Kilkenny, MD (Valley Health Systems), Ken Seen, MD and Augusta
Kosowicz, PA-C, Brenda Jarvis, RN (Roane), Dennis Small, DO (WVSOM - Clinic), Jewel Workman, RN (Man), Shannon Sigley (Camden On Gauley), Richard Crespo (Marshall University Medical School), Shawn Chillag (WV Diabetes Control Program), Beverly Begovich AND Karen Mullins (Carelink HMO) and Barbara Batiska, PA (Mini Hamilton).
Measure | ADA Guidelines | WVPCA Work Group Recommends |
| Ht | 1/ever | same |
| Wt | 1/year | 2/year |
| Type of Diabetes Recorded | 1/ever | same |
| Date of Diagnosis Recorded | 1/ever | same |
| Basic Diabetes Education including Diet and Exercise Prescription | 1/ever | 1/ever |
| Annual update of basic education and Self Management Goals including Tobacco Avoidance | 1/year | 1/year |
| Episodes of Hyperglycemia and Hypoglycemia recorded | 1/ever | every visit; at least 2/year |
| BP Check | 2/year | every visit; at least 2/year |
| Check Medication List Specify type of treatment | 2/year | every visit; at least 2/year |
| Flu vax | 1/year | every Fall |
| Pneumovax | 1/ever | same |
| A1C | 4/year on insulin 1/year not insulin | every 6 months |
| Baseline EKG | 1/ever | same |
| Partial UA/Dipstick only | 1/year | same |
| Micro Albuminuria screen | 1/year | no consensus |
| Serum Creatinine | 1/year | same |
| Cholesterol & TG | 1/ever (If normal) | 1/year |
| Foot Exam (pulses, skin, nails, sensory) | 2/year | same no consensus on exact contents |
| Eye Exam | Regular 2/year Comprehensive Specialist exam 1/year | PCP fundiscopic 1/year AND specialist referral |
| Oral Exam | Dentist 1/year | 1/year AND dental referral |
| Cardiovascular Risk Assessment | 1/year | |
| Aspirin Prophylaxis | As indicated | As indicated |
| ACE Inhibitors | As indicated | As indicated |
Greatest priorities in improving Primary Care of Diabetes should be:
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