Pre-Visit Planning: A Process Associated with Improved Outcomes in Pediatric Inflammatory Bowel Disease

T Thompson, J Scholl, A Lamb-Schnitzer, K Aka, K Jacquin, S Thompson, T Todd, S Joerger, E Utterson, R Rothbaum, C Samson

Washington University Pediatric and Adolescent Inflammatory Bowel Disease Center at St Louis Children’s Hospital Department of Pediatrics, Division of Gastroenterology, Hepatology & Nutrition Washington University School of Medicine, St Louis, MO

AbstractIssue/Background: Inflammatory bowel disease (IBD) represents a chronic illness characterized by remissions and relapses. Relapses result in missed school and/or hospitalization. With limited treatment options, best outcomes require highly reliable care delivery processes. ImproveCareNow is a multi-center learning health network with a goal of improving outcomes in pediatric IBD through QI methodology. The chronic care model was used to develop interventions to improve outcome measures, including pre-visit planning (PVP). PVP is a work flow process that systematically appraises our patients’ status and prioritizes goals for their multidisciplinary visit to anticipate needs beforehand. PVP allows the patient’s disease course; psychosocial and nutritional statuses to be reviewed, as well as updating missing labs results, medication changes and/or providing self- reported symptoms to providers to address during their visit.

Goal/Project/Method: Our overall AIM is to improve our IBD patient population’s clinical remission rate. The goal of this project was to create a highly reliable process for PVP. The Washington University Pediatric and Adolescent IBD center at St Louis Children’s Hospital began enrolling patients within the ImproveCareNow collaborative in 7/2012 and began testing in PVP in 1/2013. Our first PDSAs was the physician leader completing a paper based PVP form requiring chart review followed by a second series of PDSAs when a data coordinator was added to our team. The ImproveCareNow collaborative then developed an automated PVP form which had clinical data pre-filled from the ImproveCareNow clinical registry and we began testing this form in 5/2013. Additional PDSA cycles included testing distribution of a list of patients with at risk/in failure nutritional status and patients with psychosocial risk factors identified to the IBD team dietician and psychologist, respectively. Finally, processes for frequent identification of add-on visits started in 1/2014 and processes for having clinical nurse coordinators review and provide additional comments to the PVP form was initiated in 7/2014.

Results: We did not have a process for PVP prior to 1/2013. Through a series of PDSAs, 100% of our patients now have a PVP form prepared prior to their visit. Associated with this process improvement, our key outcome measure, clinical remission rate, increased from 65% in 7/2012 to 80% in 12/2015.

Lessons Learned/Conclusion: Through a series of PDSAs, we have created a highly reliable process for PVP in our IBD clinic and accordingly achieved improvement in our population’s remission rate. Our project demonstrates how chronic illness outcomes can be improved through QI methodology.

Background• Inflammatory Bowel Disease (IBD) is a

chronic immune-mediated affecting the intestinal tract with approximately 1-1.5 million people in the US with this diagnosis and between 17,000-93,000 newly diagnosed patients each year.

• This condition requires maintenance medications and frequent outpatient visits to prevent relapses which can result in missed school/work and/or require hospitalizations

• Treatment options are limited and several studies have examined variation in the care of IBD patients indicating a need for QI interventions.

• ImproveCareNow is a multi-center learning health network which was formed in 2007 with a goal of improving outcomes in pediatric IBD through quality improvement methodology

Background• Inflammatory Bowel Disease (IBD) is a

chronic immune-mediated affecting the intestinal tract with approximately 1-1.5 million people in the US with this diagnosis and between 17,000-93,000 newly diagnosed patients each year.

• This condition requires maintenance medications and frequent outpatient visits to prevent relapses which can result in missed school/work and/or require hospitalizations

• Treatment options are limited and several studies have examined variation in the care of IBD patients indicating a need for QI interventions.

• ImproveCareNow is a multi-center learning health network which was formed in 2007 with a goal of improving outcomes in pediatric IBD through quality improvement methodology

Conclusions• Created reliable process in pre-visit

planning and now all IBD visits have pre-visit planning completed

• Dedicated staff and resources essential for successful interventions

• Improvement in process measures correlated with increase of our population’s remission rate

• Outcomes in chronic illness can be improved through QI methodology

86 Pediatric Centers

24,500 children

1

Enrollment & Data Quality

• Identify/enroll population

• Standardize data collection

Adequate nutritional intake

Consistent, Reliable Care

• Protocols for “model” care

• Nutritional AlgorithmPopulation Management

• PM report

Appropriate growth monitoring

Appropriate drug selection and dosage

Pre Visit Planning

• Automated PVP reports

Project Aims:

By December 31 2016, ImproveCareNow

teams will achieve the following targets:

• Visits with complete

documentation bundle >95%

• Patients not taking prednisone

>95%

• Patients in remission

>80%

Informed, activated and engaged patients and

families

Self-Management Support

• SMS Handbook

• Transition Checklist

Accurate diagnosis and disease

classification

Prepared, proactive practice team

ImproveCareNow Key Driver Diagram

Methods• Compiled a list of patients followed at

Washington University/SLCH Pediatric IBD Center through an electronic health record search using ICD9 codes

• Data elements captured at every outpatient visit through templated EHR notes and began data entry in 7/2012

• Began PDSA testing in pre-visit planning in 1/2013

Aim• Overall AIM is to improve our IBD patient

population’s clinical remission rate

• Project goal to create a highly reliable process for pre-visit planning

Data Quality

Current Process Flow Diagram

• Capturing data• Every patient, every visit• Symptoms, exam, medication,

labs, outcomes• Build into workflow with minimal

duplication of effort

• Planned, prepared visit

EHR Templated IBD Note

I2B2 Web Based Data Entry

Pre-Visit PlanningPre-visit Planning PDSAs

2013-2015• Physician leader completed paper

based PVP form requiring chart review • Data coordinator added to the team• ImproveCareNow collaborative

developed an automated PVP for m which has clinical data pre-filled from the ImproveCareNow clinical registry.

• Distribution of a list of patients with at risk/in failure nutritional status and patients with psychosocial risk factors identified to the IBD team dietician social worker and psychologist respectively

• Frequent identification of add-on visits • Clinical nurse coordinator to review

and provide additional comments to the PVP

Improved Clinical Remission!

Multidisciplinary Needs List

Pre-Visit Planning Process Reliability

Effects of Pre-visit Planning• Are medication doses appropriate?

• Guidelines on form• What labs are needed ?

• Pre-filled for providers, not digging through chart

• Who needs to see the psychologist, social worker and/or dietician ?

• Identified ahead of time and noted on PVP form