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Featuring Westwood-Mansfield Pediatrics

This is one in a series of stories about strategies primary care practices are using to increase patient engagement. MHQP is in a unique position to learn about structural programs and innovative practices that help empower patients to be active in their own care, as we have recently completed a first-of-its-kind statewide study of patient engagement activities in primary care practices in Massachusetts with the support of CRICO.

The “Holy Grail” of patient engagement is self-management – patients taking an active role in managing their own care.

Patients with chronic conditions are frequently in the best position to manage their own care. Effective practices provide the support and encouragement to help people with chronic conditions and their families understand their central role in managing their illness, make informed decisions about care, and engage in healthy behaviors.

Enabling patients to make good choices and sustain healthy behaviors requires a collaborative and trusting relationship between healthcare providers and patients and their families. This partnership supports patients in building the skills and confidence they need to lead active and fulfilling lives.

One practice that shines in this area is Westwood-Mansfield Pediatrics in Westwood, Massachusetts. Lester Hartman, MD, describes his breakthrough thinking and innovative approaches to self-management with asthmatics and home strep tests:

Asthmatic Patients:

“Early in my practice, I had a mother of an asthmatic child come to me and say, ‘Look, I’m tired of going to the ER. They give three nebulizer treatments and oral steroids and send us home. Why can’t I do that myself at home?’ And that’s how the whole asthma program began – by listening to the patient. One of my favorite teachers, Dr. Warner Slack, said, “The greatest untapped resource in healthcare is the patient.” And in pediatrics, you’d have to say the family as well.

So, I started looking at data and I discovered that asthma is an incredibly predictable disorder. You know the fall and the spring are going to be worst. So, because of the predictability, you develop tools to teach parents how to self-manage their kids, get them prepared in advance, and explain the disease process to them. And more important is making the initial diagnosis when they’re young, rather than letting them have recurrent pneumonias or recurrent ER visits before you finally say, hey, they have asthma. That’s not an uncommon thing – half of all admissions to hospitals in asthmatics are under age 5, although, I think that dynamic is changing right now.

Back in 1997, we developed an asthma plan that included steroids in the Red Zone (when the patient is really sick), which pediatricians at the time were totally averse to. We developed the plan over the years. It’s gone through 6 or 7 new editions and there’s still information in there about steroids in the Red Zone. Plus, we give a nighttime asthma attack plan, so they can manage it at home initially. In addition, twice a year, we put out reminders – because again, it’s a predictable disease. In August, we ask, ‘Do you have your asthma plan? Do you have your medications?’ And then in late February or early March, we do it again for the springtime. We do this for all asthmatics in the practice. Sometimes we send these reminders to everyone. And then we put out videos that we’ve made. The beauty of these videos is we get a little poetic license – we don’t have to have perfect dialogue, we can stumble a little bit, we don’t have to have perfect lighting. We just need to get the information out – like, how to use an asthma plan or how to use your holding chamber or what can you do in your environment to prevent asthma attacks in the future? So, we put these videos out in the fall and spring to remind people. We go out on social media with it as well – we put it on Facebook, reminding people.

The next thing we do is we have a disease-specific nurse, close to what people call a community healthcare worker. For example, when we have a patient that has an exacerbation, and went to an ER or is hospitalized, the nurse will put a reminder in her calendar to call the family next year two weeks short of the time the kid was seen in the ER – and she’ll ask, do you have your meds (including oral steroids), do you have your plan and the nighttime asthma attack plan, are you clear, are you ready?

Then the other step we do is I review every week all the kids in the practice who came in with an asthma exacerbation or have a nebulizer and I make suggestions to the other providers, which is a very difficult thing in a lot of practices because providers silo themselves. Our practice has always had an attitude that that’s fine, whatever’s best for the patient.

The other thing we’re doing is we’re giving oximeters, the little thing you put on your finger to measure oxygen. If somebody goes to the ER or has a bad exacerbation in the office, we give them an oximeter to go home with. We explain to them how to use it and when it’s good to do it and when it isn’t. And I’ve posted a video on how to use it.

Asthma is a disease that’s ideally suited for self-management because it’s predictable and it’s easy to treat. It’s sometimes hard to diagnose – because the criteria are so unclear for kids under 6 – and sometimes people may not be aggressive enough about diagnosing it. So, that’s the biggest problem. But it’s so easy to teach parents. As long as you have a system in your office of nurses teaching things. It’s that personal touch. So those are the things in the asthma program – the plan, proactively alerting people, making sure people follow-up for visits.”

Home Strep Testing:

“Again, this was parent-driven. In 2006 on a Sunday, I got a phone call from a mother who said to me, ‘My kid’s strep test is positive. Can you call in an antibiotic?’ I said, ‘Oh, that’s interesting. How did you get that?’ She said, ‘It’s easy, it’s on Amazon.’ Sure enough, I click on Amazon and you can get a home strep kit in boxes of 25. This mother tells me her sister is a medical technologist, so she tested the kid. So, I said, ‘Well, I really need you to come in, but I’m intrigued with the story.’ At this point, I was risk averse and just not comfortable with the idea. So, I made three phone calls. Number one, what is the biggest fear about strep? Rheumatic fever, which causes heart damage. So, I called a cardiologist at Children’s Hospital, the largest cardiac program in the world and he told me they see only two cases per year – and we’re talking about a group that sees thousands and thousands and thousands of visits per year. So, then I called rheumatology because rheumatic fever also causes swollen joints, like arthritis. They see two cases per year also – and I’m saying to myself that it must be the same two that cardiology sees. Then I called infectious disease and asked how long it takes from the time someone gets strep to somebody getting rheumatic fever and what does the fever usually have to be? He said they have to have fever and sore throat for at least 7-10 days. I said to myself, no parent in this area is going to wait 7-10 days.

So, I said, what the heck, let me give this a shot and see what happens. I started piloting it with a few kids, giving them home strep tests, just to see how it would work. We laid out how to do the swab, how to assess the test, and gave some tips.

Like asthma, strep is a predictable disease. We don’t think of it like that, but it is. It begins roughly November and ends roughly April or by mid-May. It’s roughly running along the same time as flu. And it starts usually at age 5 and ends usually by age 12. You get much fewer kids under 5 and much fewer over 12 who get strep.  So, it’s a very predictable group – the 5-12 year olds. And you have well check-ups every year with them. So, I asked my partners if I could mail out 2,000 strep tests with instruction kits that we designed – what strep is, what the concerns are. The kits also explained when not to use it. That’s just as important because one of the worries was that we’d have all these kids who carry strep, but don’t really have it, come in and we would over-treat them. That has not turned out to be the case.

So, we sent out 2,000 kits. And when we look at the total number of visits for sore throats, compared to other practices and compared to us the year before, we had a 27% reduction in office visits for sore throats. Sore throats by volume were the number one visit in our practice back then. It’s now dropped to like number four in our practice now. And so that was a big success.

The primary purpose of this effort was to reduce acute, non-urgent visits, so we could spend more time on the important things with kids. 75% of the time, this test is negative. So, most people won’t need to come in. Now that we’ve done this for 9 or 10 years and have had no harm, we now will give people an antibiotic prescription if they call. Parents don’t like giving antibiotics to their kids any more. When I first started, people wanted their kids to be on antibiotics for colds all the time, but that attitude has changed. As a result, we will call in an antibiotic if a parent tells us they have a positive strep test at home, and the nurse reviewed it closely to make sure they did the test properly. We have a short video online that I did about how to properly swab a kid’s throat. It has had about 80,000 hits. And I did one on when a sore throat isn’t just a sore throat, where it could be dangerous, because that’s the thing that scares people. So, the purpose is to reduce the acute, non-urgent visits, to focus on the medical home and practice at the top of your license with higher, complex needs in your patient. When people look at managing patient care in the medical home, they focus on the complex kid. They don’t focus on how can I reduce the volume, make a good living, and have more time with the patient. The big problem is the time. They’re not taking the 10,000 foot view – if I cut back on these acute, non-urgent visits, I can spend more time with the patients who can most benefit from the time.

Now, a pediatric group still could think that we’re crazy. That’s money. I don’t mean to be cynical, but those are visits and that’s how we make our living. And the reality of it is we have to figure out a business case for doing these kinds of things. So, we started focusing more on chronic diseases – obesity, ADHD, learning style issues, depression, etc. And my partners are all happy about it. They could have stopped me a long time ago on this. But they’ve seen the wisdom of it. They’re happy to offload these acute, non-urgent visits to spend time on other issues. So, then you have to learn how to code properly to be able to make a living.

Now we do it on every well check-up between 5 and 9, they get a free home strep test in a packet explaining it and sending them to the video. Parents can also come by and buy a packet for $8. I’ve heard from front desk people that parents come in, buy a packet, go down to their car and swab the kid’s throat. If it’s negative, they take off. But now-a-days, if it’s positive, we’ll call the prescription in without seeing them. Because we’ve had so many years of no harm – so we felt we could take it to the next level.

Of course, the risk is someone will lie with their results. Other pediatricians tell me they’re going to call in for an antibiotic even if their kid doesn’t have strep. The old days, I might have seen that. But not now. Most young families don’t like giving antibiotics. So, the benefit outweighs the risk. This all goes back to trust. Do you trust families and their judgment?

So, that’s what we’re trying to do – help parents to manage these things. These are two self-management programs that we think are key. Sore throats and asthma were such a large chunk of visit volume that can be significantly reduced with parents involved. It’s good for the patients and for the practice.”

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