PM3021: A Care Process Model as an Education and Advocacy Tool for Children New to the United States

Purpose/Objectives: To create a care process model regarding initial evaluation and management for children who recently arrived to the United States for inpatient and outpatient use at a large children’s hospital and health system.

Design/Methods: The care process model (CPM) was created by a multidisciplinary team including members from hospital medicine, primary care, adoption medicine, infectious disease, hematology, social work, and quality improvement. The CPM included an algorithm that guides the care and navigation of newly presenting immigrant/refugee children, a supporting document with rationale of medical screening and treatment, and clinical decision support tools. Inpatient- and outpatient-specific recommendations based on presence or absence of refugee or asylee status and previous medical care were addressed in the CPM. The clinical decision support tools included an order set within the electronic medical record and a clinical documentation aid that may be inserted into patient encounter notes.
National guidelines including CDC’s Domestic Screening Guidelines for Refugees and CareRef provided the basis of evaluation and management recommendations. Since national guidelines leave flexibility for implementation in institutions, our local multidisciplinary team determined best practice consensus to create recommendations for our institution based on resources and existing infrastructure.

The CPM’s availability and contents were disseminated via 15-minute education sessions at staff meetings to hospitalists and primary care providers (PCPs). Session outcomes were assessed via pre/post surveys of participants.

Results: Eleven pediatric hospitalists and 15 PCPs completed the pre/post survey. After the session, awareness of the order set increased from 43% (6/14) to 100% (11/11) for hospitalists and 60% (9/15) to 93% (14/15) for PCPs. On a 5-point scale, confidence in the provider’s own ability to order the correct CDC-recommended screening labs increased from a mean of 2.73 to 3.91 for hospitalists, t(10) = 6.50, p < .001 and from a mean of 2.40 to 3.73 for PCPs, t(14) = 3.84, p = .002. On the same scale, provider understanding of the role of refugee resettlement agencies increased from 1.90 to 3.60 for hospitalists, t(9) = 5.67, p < .001 and 2.33 to 4.13 for PCPs, t(14) = 5.28, p < .001.

Conclusion/Discussion: A hospital system-wide CPM provides opportunities for ease and consistency in delivering evidence-based care for immigrant/refugee children. Pilot data showed that introduction to the CPM via brief, 15-minute educational sessions increased confidence among healthcare providers with ordering indicated screening labs. Future work will track utilization of the clinical decision support tools, fidelity to ordering appropriate screening labs, and establishment of a primary care home. The development of this CPM occurred within the context of a hospital-wide initiative to increase adherence to evidenced-based care. This pilot project shows promise for care process models as a tool for education and advocacy for specialized patient populations like immigrant/refugee children.