Implementation of referral guidelines at the interface between pediatric primary and subspecialty care.

BACKGROUND: In pediatric medicine, inadequate access to subspecialty care is widespread. Referral Guidelines are structured tools that describe criteria for subspecialty referral and may decrease medically unnecessary referrals and thereby improve access. PROBLEM: Variation in referral rates and suboptimal communication around pediatric subspecialty referrals leads to inappropriate and ineffective use of scarce clinical resources. GOALS: Connecticut Children׳s Medical Center prioritized the development of collaborative care tools at the interface between primary and subspecialty care, including Referral Guidelines. STRATEGY: A comprehensive set of Referral Guidelines was developed and consisted of background information on a given condition, strategies for initial evaluation and management, instructions for how and when to refer, and what the patient and family could expect at the visit with the subspecialist. A key component of the initiative was the integral role of the PCP during development. RESULTS: Twenty-eight Referral Guidelines have been developed among 15 subspecialty areas. A novel process for active dissemination of Referral Guidelines was piloted in one medical subspecialty area and led to a reduction in overall referrals and an increase in the proportion of referrals meeting the necessary criteria.

Impact of Co-management at the Primary-Subspecialty Care Interface on Follow-up and Referral Patterns for Patients With Concussion.

BACKGROUND: Co-management is a collaborative care model that consists of structured tools to define and document care delivered by 2 or more providers. We evaluated the impact of implementing co-management at the interface between pediatric primary care providers (PCPs) and subspecialists. METHODS: Participating PCPs (n = 9) were trained on management of concussion using the co-management tools. Co-managed patients with concussion were prospectively enrolled (n = 148) and compared to a retrospective audit of non-co-managed patients (n = 50). RESULTS: PCPs using co-management demonstrated adherence to the tools. PCPs were significantly more likely to provide follow-up care to patients when using the co-management tools. All participating PCPs reported that co-management enhanced their expertise in caring for patients with concussion. CONCLUSIONS: Co-management can enhance PCPs' capacity to independently manage the care of patients with concussion. Co-management led to an observed change in practice that merits further exploration in terms of cost, quality, and clinical outcomes.

Engaging pediatricians in developmental screening: the effectiveness of academic detailing.

Use of formal developmental screening tools in the pediatric medical home improves early identification of children with developmental delays and disorders, including Autism Spectrum Disorders. A pilot study evaluated the impact of an academic detailing module in which trainers visited 43 pediatric primary care practices to provide education about implementing developmental screening tools in well-child services. Attendees responded to a post presentation survey stating that they planned to implement screening in their practices. Medicaid billing data showed an increase in the state's overall rate of screening. An audit of medical charts in five practices that received the training and five that did not showed higher screening rates in practices that received the training as well as higher rates after the training than before. These pilot study results indicate the potential of academic detailing as an effective strategy for improving rates of developmental screening.