KEY ACTIVITY #12B:
Incorporate Prevention Activities within Sick Visit Appointments
This key activity involves all seven elements of person-centered population-based care: operationalize clinical guidelines; behavioral health integration; address social needs.
Overview
Ensuring that prevention activities are incorporated into sick visit appointments expands access to care and facilitates a whole-person care approach. This creates opportunities to build interventions that are responsive to patients’ and families’ needs and preferences for engaging in the health system.
Sick visits provide a chance for pediatric care providers to incorporate elements of well-care visits:
- Health history.
- Physical developmental history.
- Mental development history.
- Complete physical exam.
- Health education and anticipatory guidance.
The American Academy of Pediatrics and the American Academy of Family Physicians recommend that children with mild illnesses receive vaccinations on schedule. Importantly, there is no health benefit to waiting to vaccinate, if a child has a mild illness. In fact, it is vital that children receive recommended vaccines on time so they are protected against serious disease.
Children can still be vaccinated if they have:
- A low-grade fever.
- A cold, runny nose, or cough.
- An ear infection (otitis media).
- Mild diarrhea.
Providing essential elements of WCVs during sick visits meets the patient and/or family where they are and maximizes the value of their time in the clinic with a focus on prevention. A sizable percentage of a clinic’s patient population will only seek care when they require a sick visit, so it makes sense to provide as much opportunity for quality care during these visits as possible.
Patients and families with lower socioeconomic status are likely to benefit from accessing preventive care whenever they are able to make time to visit the clinic. For example, caregivers who balance competing demands may struggle to keep scheduled well-child visit appointments and benefit from their child having the opportunity to engage in preventive care during a sick visit. Due to financial constraints, patients and their families also may prioritize urgent care over routine or preventive care.
Clinical decision support to prompt the care team to attend to well-child or preventive care during all visits is an effective strategy. Ideally, these could be positioned to be available to the extended care team and not restricted to the medical provider. Prompting strategies can be reinforced through the availability of care guideline-driven order sets and standing orders (see above) available in the EHR.
Care quality and care gap reports, analyzed against visit history can be utilized to track progress by provider and care team in leveraging sick visit opportunities to meet guidelines.
Action steps and roles
1. Consider providing additional time for sick visits that will include WCV activities when scheduling the appointment.
The office staff who are scheduling sick visits can be helpful at that by identifying that the child is due or overdue for well-child care and booking the visit as a well-child visit and problem-directed visit and providing a longer visit. Additionally, office staff can use patient messages, medication refill requests, and phone calls as touchpoints to screen for preventive care needs and opportunities.
2. Use pre-visit planning.
Suggested team member(s) responsible: QI lead, care team lead, frontline staff.
Use a pre-visit planning process to identify which patients with scheduled sick visits would benefit from the inclusion of well-care visit (WCV) activities. Determine priority WCV activities to include for each sick visit, such as administration of recommended immunizations. See Key Activity 5: Develop of Refine and Implement a Pre-Visit Planning Process for more information.
3. Empower rooming staff to engage patients in the decision to do the preventive care activity.
Suggested team member(s) responsible: Director or care team lead.
Screenings, especially behavioral health screenings, require rooming staff to read the room to decide whether to go ahead with the screening. Considerations include that screenings can lengthen a visit and/or raise topics that patients may not be prepared to tackle when feeling unwell. Parents may also be more stressed, sleep-deprived or worried during a sick visit, potentially biasing results of screening. Care team leaders can empower rooming staff to offer screenings and to express the importance of patients’ own priorities, especially if patients feel limited by their time or are feeling too unwell to complete screenings.
4. Test new and adapted practices and processes to develop improved workflows and standard protocols for implementing WCV activities during sick visits, focusing first on prioritized areas for improvement.
Suggested team member(s) responsible: QI lead with frontline staff (as appropriate for the WCV activity of focus) and patients their families.
Coordinate with the clinic’s efforts to improve reliability in meeting WCV recommendations. Consider using the individual WCV resource pages at AAP’s parent-facing website HealthyChildren.org to design, organize, and improve the inclusion of WCV activities during sick visits. Consider testing different versions of who does what, where, when, and how, and you might be able to leverage technology to automate or partially automate some of WCVs. See Key Activity 2: Assess and Improve Reliability in Meeting Well-Child Visit (WCV) Recommendations.
Ensure that your practice is benefiting from billing for a concurrent WCV and evaluation and management (E/M) services, for which higher reimbursement is available, if correctly coded.
You may also consider extending these workflows and protocols to implement WCV activities during other visit types as well, including nonurgent follow-up visits for chronic conditions (e.g., asthma, ADHD).
Peer example: At Children’s Hospital Primary Care Clinic (CHPCC) at Vanderbilt, a quality improvement team developed key drivers and used a people-process-technology framework to devise three interventions to reduce missed opportunities for WCVs at acute visits for patients overdue for those services. Key drivers included: an electronic indicator based on novel definitions of early and periodic screening, diagnosis and treatment (EPSDT) status (e.g., up-to-date, due, overdue, no EPSDT); a standardized scheduling process for acute visits based on EPSDT status; and a dedicated nurse practitioner to provide WCVs at acute visits. Data were collected for one year after full implementation. Implementation of interventions focused on people, process and technology significantly increased WCVs at acute visits within a feasible and practical model that may be replicated at other academic general pediatrics practices.