Longitudinal, multidisciplinary, resident-driven intervention to increase immunisation rates for Medicaid, low-income and uninsured patients.

INTRODUCTION: More payers are closely linking reimbursement to high-value care outcomes such as immunisation rates. Despite this, there remain high rates of pneumonia and influenza-related hospitalisations generating hospital expenditures as high as $11 000 per hospitalisation. Vaccinating the public is an integral part of preventing poor health and utilisation outcomes and is particularly relevant to high-risk patients. As part of a multidisciplinary effort between family and internal medicine residency programmes, our goal was to improve vaccination rates to an average of 76% of eligible Medicaid, low-income and uninsured (MLIU) patients at an academic primary care practice. METHODS: The quality improvement project was completed over 3 months by three primary care resident groups. The setting was a suburban academic primary care practice and eligible patients were 18 years of age or older. Our aim was to increase immunisation rates of pneumococcal, influenza, varicella, herpes zoster virus and tetanus and diphtheria vaccination. There were 1690 patients eligible for the vaccination composite metric. Data were derived from the electronic health record and administrative data. INTERVENTIONS: Cohort 1 developed an initial intervention that consisted of a vaccine questionnaire for patients to complete while in the waiting room. Cohort 2 modified questionnaire after reviewing results from initial intervention. Cohort 3 recommended elimination of questionnaire and implementation of a bundled intervention approach. RESULTS: There were minimal improvements in patient immunisation rates after using a patient-directed paper questionnaire. After implementation of multiple interventions via an improvement bundle, there were improvements in immunisation rates which were sustained and the result of special cause variation. CONCLUSION: A key to improving immunisation rates for MLIU patients in this clinic was developing relationships with faculty and staff stakeholders. We received feedback from all the medical staff and then applied it to the interventions and made an impact in the average of vaccinations.

Evaluation of a student-led midwifery group practice: A woman's perspective.

BACKGROUND: . OBJECTIVE: To evaluate women's experiences of a student-led midwifery group practice. DESIGN: A mixed methods design was used to examine women's experiences and level of satisfaction about a student-led midwifery model of care. An on-line survey elucidated women's levels of satisfaction and experiences with the student-led midwifery group practice. The online survey was sent to all women (n = 25) who were receiving care from third year Bachelor of Midwifery students in 2018 via email up to 6 weeks postnatally. The online survey was distributed in the first instance to obtain baseline information about the importance of this student-led midwifery group practice and so the survey information was linked to the in-depth interview in the analysis for the purpose of identifying if the women were primiparous or multiparous. Women (n = 9) were invited to participate in an in-depth interview by self-opting on the survey and this extra data provided a richer understanding about the level of satisfaction about woman-centred care led by midwifery students. Retrospective data were also collected from the Maternity database - E-Maternity about birth outcomes. SETTING: A tertiary teaching public hospital in New South Wales (NSW). PARTICIPANTS: Fifteen women participated in an online survey. Five primiparous and four multiparous women opted to be involved in the in-depth interviews on the online survey. MEASUREMENTS AND FINDINGS: Analysis in SPSS provided descriptive statistics including frequencies and percentages of data including birth outcomes. Simple correlations enabled associations to be established between levels of satisfaction, individualised care, quality of care, benefits and anxiety during pregnancy. The overarching themes from the qualitative findings identified the students' presence for the women as the most important component of the women's journey. The four main themes that emerged from the study included: familiarity of the caregiver, staying informed on the journey, feeling supported and reassured by their expertise, and control and decisions over birth events. KEY CONCLUSIONS: For a variety of reasons, women valued the presence of the students throughout their childbearing journey, including valuing the woman's private space during labour and her time with her partner. This combination of pedagogical approaches provides an alternative to the current placement approach, which includes working shifts in all areas of maternity. This approach will better support midwifery students to achieve the skills necessary to provide a continuity of care experience (CoCE) amongst a small team by a student-led midwifery group practice that is supported by a registered midwife in the antenatal clinic. The midwifery student is able to develop a relationship with the woman as a component of the CoCE under the guidance of a registered midwife and this is an important underpinning of the philosophy of woman-centred care. IMPLICATIONS FOR PRACTICE: This model of care provides evidence that women do value the students' support and presence throughout their experience and that the benefits of this model should be offered to all women as a normal component of their midwifery care.

Enhancing Adherence to Cervical Cancer Screening Guidelines at a Student-Run Free Clinic.

Women who lack health insurance have much lower rates of cervical cancer screening and higher rates of cervical cancer than insured women. The current screening rate for insured patients is 86.9%, while the rate for uninsured women is 68.2%. Student-run free clinics may help increase the rates of cervical cancer screening in uninsured women. As screening rates in this setting are uncertain, this study was performed to determine rates of cervical cancer screening at a student-run free clinic, and therefore determine its effectiveness in increasing screening rates in uninsured women. A retrospective chart review was conducted among female patients ages 21-64 at a student-run free clinic to determine how many patients were up-to-date with cervical cancer screening per American Cancer Society (ACS) guidelines. A total of 239 women were included in the retrospective chart review. At their most recent visit, 87.9% of clinic patients were up-to-date on cervical cancer screening. This screening rate is higher than both the reported uninsured (68.2%) and insured (86.9%) national screening rates in the United States. Although there are multiple barriers that prevent uninsured patients from undergoing cervical cancer screenings, screening rates at our student-run free clinic are higher than national screening rates. This higher screening rate can be attributed to a standardized screening system, access to resources including Pap tests provided by community partners, and the clinic's ability to longitudinally follow patients. However, there remain areas for improvement, such as reducing no-show rates and ensuring that staff screen for cervical cancer at each visit.

TotShots: An Innovative Pediatric Free Clinic Providing High Patient Satisfaction to the Underserved.

BACKGROUND AND OBJECTIVES: The University of Arizona College of Medicine-Tucson TotShots clinic is a student-developed, student-directed free clinic that provides sports physicals and vaccines to uninsured pediatric patients in Tucson, Arizona. TotShots runs under the greater umbrella of the Commitment to Underserved People Program, which aims to teach medical students how socioeconomic and cultural factors impact health and access to health care. Our objective was to study cost savings and patient satisfaction of this clinic. METHODS: Value of care provided through sports physicals and vaccine administration was calculated using the Centers for Medicare and Medicaid Services Physician Fee Schedule and Centers for Disease Control Vaccines for Children Decisions Analysis Model. In addition, patient satisfaction was measured through the utilization of an optional three-question survey completed by patients in their preferred language at the resolution of their visit. Vaccines and sports physicals were administered from April 2017 to November 2017. RESULTS: TotShots administered 51 vaccines and completed 115 sports physicals resulting in a value of $415.65 of administration fees and $5,878.80 of sports physical examinations. Sixty-three of 66 total patients completed patient satisfaction surveys. Of those patients, 57 (90.5%) were highly satisfied with their provider's communication, 58 (92%) rated their perception of the quality of medical care they received as excellent, and 54 (85.7%) of patients were highly satisfied with their overall TotShots experience. CONCLUSIONS: TotShots fills a valuable role in increasing access to vaccines and sports physicals while maintaining high patient satisfaction and high value of cost savings.

Evaluation of multidisciplinary and pharmacy-only student-run clinics on student's perceptions of interprofessional roles.

BACKGROUND AND PURPOSE: To determine how participation in multidisciplinary training workshops and student-run clinics impacts students' perceptions of the role of other health professions. Student perceptions from pharmacy-only versus multidisciplinary smoking cessation clinics were also compared. EDUCATION ACTIVITY AND SETTING: Students from pharmacy, osteopathic medicine, physician assistant, and clinical psychology programs participated in two multidisciplinary smoking cessation training sessions, then provided smoking cessation services to the underserved population in either a multidisciplinary or pharmacy-only student-run smoking cessation clinic. Students completed a survey regarding the roles of other healthcare professionals prior to the workshops, after the workshops, and after the smoking cessation clinic. FINDINGS: Fifty-six students attended both smoking cessation training sessions and showed statistically significant increases in familiarity and confidence related to smoking cessation after the training workshops. Forty-two students participated in the ten smoking cessations clinics, which included six multidisciplinary clinics and four pharmacy-only clinics. A statistically significant improvement was seen between the pre-workshop survey and post-clinic survey regarding the students' perception of the roles of other healthcare providers in a smoking cessation clinic. Students who participated within the multidisciplinary smoking cessation clinics experienced a significantly greater impact on their perceptions of other healthcare providers than students who participated in the pharmacy-only clinics. SUMMARY: Student participation in a student-run free clinic is an effective method to increase role awareness of other health professional students in an underserved setting.

Impact of Pharmacist Previsit Input to Providers on Chronic Opioid Prescribing Safety.

INTRODUCTION: Primary care providers (PCPs) account for half of opioid prescriptions, often feel chronic pain patients are challenging to manage, and there is wide variability in practice patterns. The purpose of this pilot study was to evaluate the impact of a previsit pharmacist review of high-risk patients treated with opioids for chronic pain on compliance to guideline recommendations at a family medicine residency clinic. METHODS: All adult patients with an appointment for chronic pain who were prescribed >50 morphine milligram equivalents (MMEs)/day had charts reviewed by a pharmacist before each appointment; recommendations were sent electronically to the provider before the appointment. After 4 months of implementation, each patient's chart was manually reviewed to gather outcome variables. The primary outcomes were the mean MMEs/day and pain scores. RESULTS: Pharmacist previsit recommendations were provided for 45 patients. When comparing outcomes before and after intervention, the mean MMEs/day decreased by 14% (P < .001), with no change in pain scores (P = .783). Statistically significant improvements were noted in multiple other secondary opioid safety outcomes. CONCLUSION: Clinical pharmacists providing previsit recommendations was associated with decreased opioid utilization with no corresponding increase in pain scores and increased compliance to guideline recommendations.

A Project-Based, Resident-Led Quality Improvement Curriculum Within a Pediatric Continuity Clinic.

Introduction: Participation in quality improvement (QI) projects is required of pediatric residents, and evidence-based medicine has highlighted the importance of providing residents with experiential practice in this realm. Embedding QI projects within a continuity clinic provides residents an opportunity for meaningful involvement in QI efforts. Methods: A QI curriculum was implemented within a pediatric residency program that included an introductory lecture on QI principles and participation in resident-led, team-based QI projects at an outpatient clinic. Residents designed, implemented, and analyzed projects beginning in their intern year. Projects operated on an accelerated, 6-month time frame, allowing residents to complete multiple projects over the course of their residency. Resident QI knowledge was assessed before and after an introductory lecture with the Quality Improvement Knowledge Application Tool (QIKAT). Resident feedback was solicited 1 year following curriculum implementation via anonymous online surveys. Results: Residents completed four QI projects that produced meaningful improvements in clinic processes and patient care. QIKAT scores significantly increased after the introductory lecture. Residents reported that the curriculum afforded them increased confidence to implement plan-do-study-act cycles and improve patient care in their future practices. Qualitative feedback highlighted the team-based structure, participation in multiple projects, and visible direct impacts on patient care as strengths of the curriculum. Increased involvement of clinic staff, scheduling concerns, and improved communication were areas for improvement. Discussion: Our model for integrating resident-led QI projects into an ambulatory clinic rotation is feasible and has been well received by residents and impactful on clinic processes and care.

Assessing quality of care through client satisfaction at an interprofessional student-run free clinic.

Student-run free clinics (SRFCs) have become important contributors not only to improve access to primary-care services for homeless and uninsured populations but also to enhance health sciences student education. In order for SRFCs to reliably provide high quality healthcare services and educationally benefit students, it is imperative to assess client perceptions of the quality of care provided. The objective of this study was to evaluate the delivery of healthcare services through a client satisfaction questionnaire at the University of California, Los Angeles Mobile Clinic Project (UCLA MCP). From 2012 to 2015, 194 questionnaires that addressed demographic information, satisfaction with services and client outcomes were analysed. Satisfaction scores were evaluated on a four-point scale and differences in the composite satisfaction scores were assessed using Mann-Whitney U-tests. Half (50%) of the client respondents report that UCLA MCP is their primary source of health care (MCP primary care clients), while 81.3% reported that the clinic improved access to other healthcare resources. Overall, clients are highly satisfied with their experiences (Range: 3.5-3.9) and 62% have recommended our services to others. While MCP primary-care clients report significantly higher satisfaction scores than non-primary-care clients on average (p < 0.01), the mean composite scores for all subgroups are consistently high. The UCLA MCP clients perceive the clinic to provide high-quality healthcare services. This article presents a framework that may help other SRFCs evaluate clients' perception of the quality of their care, an essential building block for effective physician-client relationships.

Assessment of Hypertension Management and Outcomes at an Indianapolis Student-Run Free Clinic.

PURPOSE: To characterize the quality of health care at student-run free clinics (SRFCs) by analyzing hypertension management and outcomes at the Indiana University Student Outreach Clinic (IUSOC). METHODS: A retrospective review of medical records was conducted for hypertensive patients managed at IUSOC over 15 months (N = 64). Indiana University Student Outreach Clinic's hypertension control rate was compared with National Health and Nutrition Examination Survey (NHANES) data. RESULTS: Blood pressure control rates increased significantly over the study period. Indiana University Student Outreach Clinic's control rate did not differ significantly with the NHANES national average, but was significantly greater than the NHANES group with no usual source of care. Similarly, IUSOC patients without insurance or with unknown insurance status had greater control rates than an uninsured NHANES group, but did not differ significantly from an insured NHANES group. CONCLUSIONS: Despite unfavorable demographic characteristics, records for patients with hypertension who used IUSOC as a regular provider of primary care compared favorably with national data.