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- All Subjects: Primary Health Care
- All Subjects: Healthcare Accessibility
- Creators: Rauton, Monica
- Creators: Thrall, Charlotte
- Member of: Programs and Communities
Description
Declaration of Conflicts: This project has no conflicts of interest to declare.
Context: This project was completed at a federally qualified primary healthcare clinic in Phoenix, Arizona that served patients of all age groups, but primarily cared for the Hispanic population providing primary care, preventative services, family planning, two lab technicians, one promoter, two medical assistant supervisors, five front desk staff, one chief administrative officer, one chief financial officer, two medical directoers who were also providers at the clinic.
Problem and Analysis Assessment: During my clinical rotations, I saw the burden a missed patient appointment had not only on the patients themselves, but also on the clinic, providers, and the staff. It caused delay in treatment for patients, and it did not allow other patients that wanted to be seen to be seen. It also increased unnecessary costs and wasted provider time. Thereafter, I met with some of the leadership team and one of the medical directors to determine a solution to reduce the number of missed appointments that were occurring. An educational session was kept to discuss the findings of this problem to the providers and the staff and when surveys were handed out to the patients, providers, and staff to assess their satisfaction with the old scheduling system versus the new scheduling system, they were also provided with a cover letter discussing the project.
Intervention: In order for improvements in care to occur, a system process change including the way patients are scheduled must occur. In this case, an open-access scheduling system (OAS) was implemented. OAS allows a patient to schedule an appointment on the 'same-day' or the 'next-day' to be seen. One provider at each of the clinics, each day of the week was available for 'same-day' appointments from 1300-1600. The providers were still available for scheduled appointments using the previous scheduling method. Walk-ins were still accepted, and were scheduled based on patient provider preference; however, if an appointment was not available for their preferred provider, they were typically seen with the provider that was the 'same-day' provider for that day.
Strategy for change: Since patients were only allowed to schedule appointments one month in advance, only one month was needed to implement this process change. A recommendation for the future would be to clearly identify the patient encounter type, and label it as a same-day appointment, as this would be helpful when gathering and extracting data for this type of patient group specifically.
Measurement of Improvement: Over a three-month period, a data collection plan was used to determine the number of Mas over a three-month period before and after implementation of this change. Satisfaction scores were measured using likert scales for patients, provider, and staff, and a dichotomous scale was used to determine the likelihood of emergency room or urgent care use. A comparison was done to measure revenue during the same time frame. During the three months, a clinically significant decrease in MAs was seen (<0.52%), with an increase in revenue by 41%. Additionally, a statistically significant increase in patient, provider and staff satisfaction was also noted when compared to the old scheduling system, as >68% of all patients, providers and staff reported feeling either very satisfied or extremely satisfied with the new scheduling system. Additionally, patients also reported that they were less likely to visit an emergency room(88%) or urgent care (90%) since they were able to be seen the same-day or the next-day by a provider.
Effects of changes: An incidental finding occurred during this study - where 877 more patients were seen in the three months during the implementation of this project, compared to the three months prior; which likely resulted in a 41% increase in revenue. Additionally this project, allowed patients that wanted to be seen on the same day, to be seen, and it decreased unnecessary costs associated with emergency room or urgent care visits. Some of the limitations involved included the current political environment, appointment slots that were previously 15 minutes in length (in 2016), increased to 20 minutes in length (in 2017), a language barrier was noted for the patient surveys since English was not the first language for many of the patients who completed the survey (although documents were translated), and the surveys used were not reliable instrument given that a reliable instrument in previous studies could not be found.
Lessons learnt: In order to have accuracy of the survey results, it is best for the author of the study to hand out and provide scripture for the survey so that complete data is received from the surveyors.
Messages for others: Begin by making a small process change where only one provider allows for the open-access scheduling so that the entire office is not affected by it, and if results begin to look promising then it can be expanded. Additionally, correct labeling of patients as 'same-day' is also important so that additional data can be gathered when needed regarding the 'same-day' patients.
Patient/Family/Guardian Involvement: Patients who benefited from the new scheduling system (open-access scheduling) were asked to fill out a survey that asked them to disclose some demographic data and asked them to determine their satisfaction with the new vs old scheduling system and their likelihood of visiting an emergency room or urgent care.
Ethics Approval: Arizona State University Institutional Review Board (IRB) Received: September 2017
Context: This project was completed at a federally qualified primary healthcare clinic in Phoenix, Arizona that served patients of all age groups, but primarily cared for the Hispanic population providing primary care, preventative services, family planning, two lab technicians, one promoter, two medical assistant supervisors, five front desk staff, one chief administrative officer, one chief financial officer, two medical directoers who were also providers at the clinic.
Problem and Analysis Assessment: During my clinical rotations, I saw the burden a missed patient appointment had not only on the patients themselves, but also on the clinic, providers, and the staff. It caused delay in treatment for patients, and it did not allow other patients that wanted to be seen to be seen. It also increased unnecessary costs and wasted provider time. Thereafter, I met with some of the leadership team and one of the medical directors to determine a solution to reduce the number of missed appointments that were occurring. An educational session was kept to discuss the findings of this problem to the providers and the staff and when surveys were handed out to the patients, providers, and staff to assess their satisfaction with the old scheduling system versus the new scheduling system, they were also provided with a cover letter discussing the project.
Intervention: In order for improvements in care to occur, a system process change including the way patients are scheduled must occur. In this case, an open-access scheduling system (OAS) was implemented. OAS allows a patient to schedule an appointment on the 'same-day' or the 'next-day' to be seen. One provider at each of the clinics, each day of the week was available for 'same-day' appointments from 1300-1600. The providers were still available for scheduled appointments using the previous scheduling method. Walk-ins were still accepted, and were scheduled based on patient provider preference; however, if an appointment was not available for their preferred provider, they were typically seen with the provider that was the 'same-day' provider for that day.
Strategy for change: Since patients were only allowed to schedule appointments one month in advance, only one month was needed to implement this process change. A recommendation for the future would be to clearly identify the patient encounter type, and label it as a same-day appointment, as this would be helpful when gathering and extracting data for this type of patient group specifically.
Measurement of Improvement: Over a three-month period, a data collection plan was used to determine the number of Mas over a three-month period before and after implementation of this change. Satisfaction scores were measured using likert scales for patients, provider, and staff, and a dichotomous scale was used to determine the likelihood of emergency room or urgent care use. A comparison was done to measure revenue during the same time frame. During the three months, a clinically significant decrease in MAs was seen (<0.52%), with an increase in revenue by 41%. Additionally, a statistically significant increase in patient, provider and staff satisfaction was also noted when compared to the old scheduling system, as >68% of all patients, providers and staff reported feeling either very satisfied or extremely satisfied with the new scheduling system. Additionally, patients also reported that they were less likely to visit an emergency room(88%) or urgent care (90%) since they were able to be seen the same-day or the next-day by a provider.
Effects of changes: An incidental finding occurred during this study - where 877 more patients were seen in the three months during the implementation of this project, compared to the three months prior; which likely resulted in a 41% increase in revenue. Additionally this project, allowed patients that wanted to be seen on the same day, to be seen, and it decreased unnecessary costs associated with emergency room or urgent care visits. Some of the limitations involved included the current political environment, appointment slots that were previously 15 minutes in length (in 2016), increased to 20 minutes in length (in 2017), a language barrier was noted for the patient surveys since English was not the first language for many of the patients who completed the survey (although documents were translated), and the surveys used were not reliable instrument given that a reliable instrument in previous studies could not be found.
Lessons learnt: In order to have accuracy of the survey results, it is best for the author of the study to hand out and provide scripture for the survey so that complete data is received from the surveyors.
Messages for others: Begin by making a small process change where only one provider allows for the open-access scheduling so that the entire office is not affected by it, and if results begin to look promising then it can be expanded. Additionally, correct labeling of patients as 'same-day' is also important so that additional data can be gathered when needed regarding the 'same-day' patients.
Patient/Family/Guardian Involvement: Patients who benefited from the new scheduling system (open-access scheduling) were asked to fill out a survey that asked them to disclose some demographic data and asked them to determine their satisfaction with the new vs old scheduling system and their likelihood of visiting an emergency room or urgent care.
Ethics Approval: Arizona State University Institutional Review Board (IRB) Received: September 2017
ContributorsPatel, Dimple (Author) / Thrall, Charlotte (Thesis advisor) / Glover, Johannah-Uriri (Thesis advisor)
Created2018-05-02
Description
Many older Americans don’t have an advance directive (AD). ADs are legal documents that allow a person to express what types of medical treatment or cares that they want at the end of their life if they were unable to speak for themselves. Patients without an AD could receive unwanted treatment. Providers can utilize advance care planning (ACP) to educate patients and support them in forming a medical power of attorney (MPOA) and AD. Evidence suggests that having ACP conversations can engage a patient to form an AD. The purpose of this project was to see if ACP discussions with older patients encouraged them to complete an AD and MPOA.
The project used a mixed method design. Participants were recruited from a primary care practice. Descriptive statistics described the sample and outcome variable. An independent t- test measured if there were significant changes in the participant responses for the ACP survey.
The average age (standard deviation) of the chart review sample was 72.22 (SD=9.47). The ages ranged from 60 to 100 years of age. Most of the sample in the chart audit were female with 105 (53%) participants and 95 (48%) were male. Most of the sample, 183 (92.5%) reported having a chronic health condition and 17 (7.5%) of the sample reported having no chronic condition. Overall, the results were inclined towards a significant difference in participants who did the ACP discussions and those who did not when comparing completed AD forms.
The project used a mixed method design. Participants were recruited from a primary care practice. Descriptive statistics described the sample and outcome variable. An independent t- test measured if there were significant changes in the participant responses for the ACP survey.
The average age (standard deviation) of the chart review sample was 72.22 (SD=9.47). The ages ranged from 60 to 100 years of age. Most of the sample in the chart audit were female with 105 (53%) participants and 95 (48%) were male. Most of the sample, 183 (92.5%) reported having a chronic health condition and 17 (7.5%) of the sample reported having no chronic condition. Overall, the results were inclined towards a significant difference in participants who did the ACP discussions and those who did not when comparing completed AD forms.
ContributorsKrasowski, Maria (Author) / Rauton, Monica (Thesis advisor)
Created2018-05-01
Description
Background: An evidence-based project was performed to train and increase skills among healthcare providers to perform advance care planning. Training decreases barriers and improves attitudes and confidence to perform advance care planning. Advance care planning can include the Physician Order for Life-sustaining Treatment, an out-of-hospital order that directs emergency medical services of a patient’s wishes. Internal evidence found that many providers are unfamiliar with the Physician Order for Life-Sustaining Treatment form. The Theory of Planned Behavior was used to guide the project.
Objectives: To improve advanced care planning processes in a healthcare organization.
Design: A quality improvement project was performed at a medical center with outpatient provider groups. Virtual training was provided by the Arizona Hospital and Healthcare Association on the Physician Order for Life-Sustaining Treatment. Participants completed a three-part survey to measure skills for advance care planning after a training event.
Setting/Subjects: Five (n=5) American palliative and primary care providers at a medical center.
Measurements: The East Midlands Evaluation Toolkit is a validated survey tool that measures confidence and competence in advance care planning after training.
Results: Descriptive statistics, Friedman’s test, and the Kruskal-Wallis test were used for data analysis. Results provided evidence to the healthcare facility that there is a significant need to train their healthcare professionals on advance care planning.
Conclusions: Recommendations are made to focus research on larger studies looking at the types of advance care planning, and differences in disciplines and specialties.
ContributorsPate, A. Shurine (Author) / Rauton, Monica (Thesis advisor) / Arizona State University. College of Nursing & Healthcare Innovation (Contributor)
Created2022-04-29
Description
Medicare implemented a yearly Annual Wellness Visit (AWV) to improve quality patient care through early detection of declining health. However, there has been only partial provider participation since its inception, which potentially delays treatment and negatively impacts patient outcomes. The aim of this quality improvement project was to assess the feasibility of implementing a standardized electronic AWV template into private primary care practices to improve the consistency of delivery and documentation. The project designer utilized the theory of transitions (TOT) to facilitate the project execution. An electronic Excel-based template was designed to capture and calculate all aspects of the AWV, including billing codes, to allow for ease and consistency of use within a small primary care practice over two weeks. A provider performed the AWVs using the electronic template after completing a hands-on tutorial and reviewing an educational handout. Data were retrieved from a 7-question, 5-point Likert scale questionnaire given to the provider to assess the effectiveness of the electronic template versus a paper assessment. The results of this study indicated overall satisfaction with using leveraged technology to provide consistency of AWVs to improve patient outcomes, provider satisfaction, and increase revenue through uniform charting and billing. The outcomes of this project provide a basis of existing evidence for using standardized methods to perform and track Medicare AWVs.
ContributorsHill, L. Michelle (Author) / Rauton, Monica (Thesis advisor) / Arizona State University. College of Nursing & Healthcare Innovation (Contributor)
Created2022-04-29
Description
Abstract: Abstract
Completion of advance directives (AD) prevent unwanted care. It is clear that systematic integration of AD documentation in primary care practices can lead to less intrusion of patient autonomy, and remove a source or moral injury and ethical ambiguity for providers, family and caregivers. The purpose of this project was to examine the effect of an evidence-based AD completion activity on AD completion rates in a rural, primary-care clinic. The theory of self-determination (SDT) guided the project as SDT describes why and how persons are motivated to engage in acts of self-determination. Recruitment was self-selective as all clients aged 18 years or older had access and opportunity to available PREPARE.org materials to complete a state specific AD in English or Spanish on site. Each patient of the clinic signed the site-specific consent form authorizing release of information for study use. Project data was collected via chart audits using a pre/post intervention design. Results indicate that passively providing AD materials, even in a multiple languages and formats is not enough to engage self-motivation to complete an AD. This attempt to improve AD completion in primary care reflects the larger body of knowledge; interpersonal communication is needed to stimulate relatedness and improved competence, the two precursors of acts of self-determination, as outlined by SDT.
ContributorsSipe, Erica (Author) / Rauton, Monica (Thesis advisor) / Arizona State University. College of Nursing & Healthcare Innovation (Contributor)
Created2021-04-25
Description
Primary health care clinics are essential first defenders determined to confront the upsurge in health-related leading causes of death in the United States. Unfortunately, the underserved or uninsured community continues to struggle to access these vital health care services. Consequently, this vulnerable population seeks venues such as community services events to obtain these unmet primary care services. Community services events effectively disseminate health-related material and provide access to vital medical services. Currently, community services strive to bridge the gap between underserved individuals and primary care clinics by providing participants referrals for low-fee or free clinics to establish ongoing care. A lack of data exists on whether these events sufficiently impact the participants to motivate them to follow-up with a health care clinic. A critical appraisal of evidence showed that follow-up adherence rates are remarkably improved by directly referring participants to a primary clinic during a community services event. This paper explores the effect on health outcomes and health disparities when establishing connections between community services participants and ongoing healthcare services.
ContributorsNavarrete, Elizabeth (Author) / Thrall, Charlotte (Thesis advisor) / Arizona State University. College of Nursing & Healthcare Innovation (Contributor)
Created2021-04-22
Description
Homeless individuals encounter barriers such as lack of health insurance, increased cost of care and unavailability of resources. They have increased risk of comorbid physical disease and poor mental health. Depression is a prevalent mental health disorder in the US linked to increased risk of mortality. Literature suggests depression screening can identify high-risk individuals with using the patient health questionnaire (PHQ-9).
The objective of this project is to determine if screening identifies depression in the homeless and how it impacts healthcare access. Setting is a local organization in Phoenix offering shelter to homeless individuals. An evidence-based project was implemented over two months in 2019 using convenience sampling. Intervention included depression screening using the PHQ-9, referring to primary care and tracking appointment times. IRB approval obtained from Arizona State University, privacy discussed, and consent obtained prior to data collection. Participants were assigned a random number to protect privacy.
A chart audit tool was used to obtain sociodemographics and insurance status. Descriptive statistics used and analyzed using Intellectus. Sample size was (n = 18), age (M = 35) most were White-non-Hispanic, 44% had a high school diploma and 78% were insured. Mean score was 7.72, three were previously diagnosed and not referred. Three were referred with a turnaround appointment time of one, two and seven days respectively. No significant correlation found between age and depression severity. A significant correlation found between previous diagnosis and depression severity. Attention to PHQ-9 varied among providers and not always addressed. Future projects should focus on improving collaboration between this facility and providers, increasing screening and ensuring adequate follow up and treatment.
ContributorsParamo, Cinthia Arredondo (Author) / Thrall, Charlotte (Thesis advisor)
Created2020-05-04