P3.A006: Improving Complex Care Management in Private Practice Using Tracking Techniques

Purpose/Objectives: Patients with Complex Chronic Care Needs require more time spent before, during and after visits, require more resources, more support and more frequent visits to address their needs. Due to push in medicine to see more patients per day Complex Care Patient visits are often rushed to keep pace with office demands. This leading them not to receive many of the resources and support they qualify for. In addition - they often are not seen as often as they should be to address all of their needs. We wanted to improve the care and resources our Chronic patients receive to ensure better health outcomes, support for families while not being rushed to keep visits short.

Design/Methods: EHR as well as personal recollection was used to Identify and tag patients "complex care". Excel file was created which lists all the patients as well as all the resources applicable to them - as well as date of last visit - in person or virtual. Charts were then audited to see if they had all the applicable resources offered and have been seen in the last 3 months. Patient recalls was initiated to those missing resources, prepared packets of resources ahead of time, to schedule an appointment (in person or virtual) and giving them the packets prepared. In 3 months we will reevaluate the date to see improvement.

Results: On initial data 30% of all "Complex Chronic Care" patients had received all the resources they qualified for and were seen in the last 3 months. Our goal was to increase this to 50% over 3 months. We are in the process of calculating data but appear to have statistically significant increase in the percentage of chronic care patients who received the resources and follow-up they needed. In addition - the number of their office visits increased which making them less rushed and stressful to the physicians.

Conclusion/Discussion: Children with complex care needs have more needs than general pediatric population. Parents often struggle to care for them due to the high needs. They look to their pediatrician and medical home for guidance and resources that can help them take care of their child. Pediatricians in private practice don't have social workers and often feel like they lack the time and ability to give these families all the resources they need in a world of fast paced private practice. Tracking chronic care patients and routinely reviewing the tracking table not only improved the number of patients receiving the resources they need but also decreased the stress on clinicians. Clinicians feel less rushed when patients are seen more often and resources are prepared ahead. The more frequent visits, whether in person or virtual, also increase revenue to the practice.