Atrium Health Levine Children's Hospital

Passport to Healing: Navigating the Path to Rheumatologic Care for Children from Safety-Net Clinics

Project Lead:  Sheetal S. Vora, MD

Project Aim(s): The aim of this project is to prevent morbidity and mortality related to rheumatic conditions in underserved pediatric populations. Our focus will be on prompt and accurate identification and subsequent treatment of rheumatologic symptoms or diagnoses for pediatric patients referred from one Atrium Health safety-net primary care clinic. Our proxy measures are:

  • 10% increase in accurate referrals for pediatric patients from one Atrium Health safety-net clinic to Levine Children’s Specialty Center (LCSC) rheumatology clinic by September 14, 2021 (i.e. approximately 17 additional patients).
  • 80% of all referred LCSC rheumatology priority patients seen within 30 business days (BD) from referral.

Narrative Description

This project found new ways to apply existing data analytics by layering symptoms data onto zip code data to uncover significant and previously unrecognized gaps in care, opening the possibility of crucial state-wide support for families struggling with social determinants of health. This was a turning point for our work.

The project applied communication strategies in new ways to improve provider education and patient care, such as combining a culturally relevant patient story with a tutorial on referral tool use; using a resident and advanced practice provider (NP) to influence their peers; and helping all members of the care team collaborate effectively to maximize limited personnel and resources.  Simple visual aids, signage, and keyboard shortcuts for the referral tool greatly enhanced referral tool usage.

As the COVID-19 pandemic erupted with strict limitations on in-person interactions and severe burdens on the healthcare system, the team pivoted from targeting all four safety-net clinics to only the main pediatric safety-net primary care clinic who saw the majority of patients captured in the data review. We thus modified our aim from four safety-net clinics to one safety-net clinic where we would focus our efforts. The one clinic that we chose to focus on is located immediately next to our main children’s specialty center, allowing the PI access. Additionally, a pediatric resident had weekly clinics at this particular safety-net clinic. The delays caused by the pandemic (limitations on in-person interactions, staff shortages due to illness and redeployments, etc.) necessitated an extension of project timelines.

Additionally, our goal to see 80% of all those referred in 30 BD from this clinic has been modified to include only those children who triage as priority 1, 2, and 3 based on clinical and laboratory criteria. Other factors that impacted the project’s progress:

  • Loss of provider in July 2021: This disruption extended the “time to be seen” measure; please see run chart #2 below and detailed explanation in section #3 Challenges.
  • EMR change in April 2022: The switch to a new EMR system briefly disrupted the rheum referral process (creating extra steps in order to get to rheum). This issue was fixed in January 2023.
  • New referral form in April 2022: This form has gone through several modifications; the current content is essentially same, but with the addition of 2 SDOH questions (transportation needs, and preferred language was added as hard stop within the EMR switch). The process for providers to submit the form is different now.

Ultimately, this project was deemed a success – due to improved communication, provider knowledge, and process efficiency, the team increased the number of patients seen from disadvantaged communities despite COVID-19 limitations and severe staff shortages. We achieved improvement, increasing from zero referrals in the previous five years for the targeted population to 15 patient referrals within one year of project initiation.

Diagnostic quality problem type, failure, or category (symptoms, observed problems, gaps in performance) addressed by the intervention

  • Patient delayed or unable to access to care
  • Information gathering
  • Information integration
  • Information interpretation
  • Establishing an explanation (diagnosis)

Root causes/causative factors addressed by the intervention

  • Patient-clinician interaction (includes patient and family engagement)
  • Workflow (includes testing, follow-up, and referrals)
  • Physical environmental or work system factors
  • Health information sharing and accessibility via health IT
  • Knowledge gaps/inexperience

Setting of the diagnostic quality improvement intervention

  • Ambulatory medical care setting (e.g., clinic, office, urgent care)