Health and Housing, Children and more: Building the bridge between the health centers and public health

Thanks to everyone who came to the report outs yesterday. I was so pleased to see such a diverse cross section of our system and of our community. This week's Kaizen team consisted of providers from as fCCRMC, HC and Public Health as well as two patient partners. The team focused on building a bridge between public health nursing and family practice clinics. Although family practice serves up two thirds of pediatric patients in CCHS we found we are not reliably referring pediatric referrals from family practice to public health nursing. Public Health provides case management and home visits to children in need of further support. Public Health Nursing is also key in delivery of services to those who are experiencing homelessness, another vulnerable group who we often treat in the health centers. Too often these groups fall through the cracks between the health centers and their homes or shelters.  This directed the scope and four target metrics for the week:

1. Decrease the defect rate of missed pediatric appropriate referrals from 50% to 0%;
2.  Decrease the defect rate of overall inappropriate referrals to public health nursing (PHN) from 25% to 0%
3.  Increase the % of screening for homelessness from 0% to 100% and
4.  Increase homeless referrals from Primary Care to Public Health from 0% to 10%.

The multidisciplinary Kaizen team tested multiple trials: creating a trigger mechanism to identify homeless patients at the time of their visit, closing the fragmented communication loop between provider, care coordinator and public health nurse to improve continuity of care for patients and improving staff education on the role of a public health nurse and referral criteria for pediatric and
homeless patients.

 The screening form assesses for homeless populations that come to our clinic sites, which may include patients who may be using our county shelter, but who are not followed due to the public health nurse not knowing about their medical needs.  The form also includes a list of other things that the patient may need help with that they can check off. 

The education team did a cross-training trial which involved having a resident physician, LVN, patient, care coordinator go out to the Concord Shelter to simulate the PHN's referral process to learn more about the PHN role through a first-hand experience.

The standard work will be rigorously implemented over the next 30 days in Martinez Health Center and will spread to the rest of the clinics to ensure successful metrics, sustainability and overall improved healthcare outcomes for patients. The public health nurse will also attend family practice staff meetings and be incorporated into new staff orientation for nurses.
I did have a chance to speak to those who attended about my visits to Congress this week and the importance of the work you are all doing. Threats and concerns about health care reform continue to loom. Local demonstration of the use of improvement and innovation are key in supporting federal policy. Our discussion that centered on supporting delivery system reform had two key themes: Integration and Innovation. I was proud to present the work we are doing in these areas and more. I encourage you to watch the video of my report on iSite.
More very soon.
Anna