(68) Increasing Care Coordination between the Primary Cystic Fibrosis Team and Gastroenterology in a Pediatric Cystic Fibrosis Care Center Utilizing the Model of Improvement

Background: Our cystic fibrosis (CF) quality improvement (QI) team is comprised of multidisciplinary team members as well as engaged patient/family partners. Our patient/family partners voiced having intentional care coordination processes in place that ensures persons with CF (PwCF) have seamless access to personalized timely care. During a transition period in which a new CF gastroenterology (CF-GI) provider onboarded it became evident that CF-GI appointments were not being scheduled consistently nor being coordinated between the CF team & CF-GI. Our global aim for this project was to improve the scheduling coordination process for CF-GI patients to optimize coordinated patient care and reduce travel and time burdens on PwCF.

Methods: We utilized the Model of Improvement to guide our improvement efforts. Our initial step was to organize our plans by creating a project charter, and our second step was to measure current care coordination between CF-GI and the CF team. In addition, a robust scheduling process map was created to understand the scheduling steps, barriers, and identify stakeholders. A simplified Failure Mode Effects Analysis (sFMEA) was utilized to list the current process, barriers (failure mode), and potential interventions. We defined measures and set goals with a SMART aim: “To increase the % of PwCF who get coordinated CF team and GI appointments from 56% to 90% by 12/31/2021.” A key driver diagram (KDD) helped us develop our theory of improvement (drivers) in order to achieve our aim. The sFMEA tool was helpful in selecting interventions in the KDD (changes) to test in a Plan-Do-Study-Act (PDSA) framework. Interventions included 1) all coordinated CF and CF-GI appointments to be scheduled by CF clinic schedulers, 2) CF clinic schedulers have access to GI schedule template, 3) Practitioners and clinic RNs identify need for care coordination in real time prior to patient leaving CF clinic, and 4) coordinated follow-up appointments scheduled in real time prior to patients leaving CF clinic.

Results: Clinic visits that were deemed appropriate for care coordination between the primary CF Team and the CF-GI provider were measured over 31 weeks for a total 77 encounters. A centerline of 60% coordinated visits was documented through week 14. During weeks 14-18 new clinic schedulers were onboarded and trained on the coordinated scheduling process. A new center line of over 90% coordinated visits was documented after week 16. A majority of coordinated clinic visits were scheduled prior to the patient leaving the previous clinic visit (71%). A communication process between clinic RNs and clinic schedulers ensured the vast majority of PwCF eventually obtained scheduled coordinated clinic visits.

Conclusions: A multidisciplinary CF QI team was able to incorporate a new CF-GI provider into our improvement team and listen to patient/family partners to identify an area for improved clinical care. By utilizing the QI tools for improvement, clinic coordination of CF-GI patients was improved from 56% to over 90%. These results demonstrate how the tools for improvement combined with relationship building and improved communication between CF care team members and key stakeholders can ultimately lead to better care coordination and reduced travel and time burdens on PwCF.

Acknowledgements: This work was support by the Cystic Fibrosis Foundation (POWERSCC028, SEID19AB0)

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