Primary Care | Quality Improvements and Education

Not only are we working every day to keep our patients and their families healthy and happy, we are also working to strengthen and improve the care we give. Here are a few of our ongoing endeavors and projects:

We have transitioned into an Accountable Care Organization, which brings our focus to delivering high-quality, low-cost care to all of our patients through reduction of unnecessary services and coordination of care. We are working to:

• focus on decreasing emergency department visits in our patients when they could have gone to urgent care clinic or talked to a nurse for care at home
• increase coordination of care services amongst our most medically complex patients through several process improvements and parent focus groups

Our patients’ safety is our highest priority. That’s why we have assembled a Safety Committee that works to identify safety events that have the biggest impact, and brainstorms ways to reduce these in our clinic. We are focusing on clear and closed-loop communication, and how it can improve our care.

We are constantly developing evidence-based guidelines to develop clinical pathways to guide care in our clinic. A few guidelines we have created are: 

• weight management guidelines for patients with an elevated BMI, including better diagnosis and proper monitoring through lab work
• first well-child check for newly arrived immigrant patients
• care plans for patients with mild to severe eczema and/or peanut allergies
• better diagnosis and care for hypertension
• management of patients with concussions who come to primary care
• better diagnosis and medication management for patients with ADHD

We are working to ensure that every patient with asthma has:

• an Asthma Control Test, to see how well their symptoms are controlled
• a classification of the severity of their asthma, to help us know what medications we should be giving
• controller medications if they need them
• an Asthma Action Plan to use at home

We are keeping track of the percent of providers following our standard of care, and the percent of patients who are reassessed after having an initial positive screen for depression. 

Dental health is important for general and long-term health. That’s why we are working to do Caries Risk Assessment on all young children, and apply fluoride varnish, which can help prevent cavities, to children at high risk. 

At every well-child visit from 6 months of age on, we ask parents to fill out questionnaires to help us identify any problems with development or behavior so that we can act early and get them any help they need. We are currently in the process of starting a 2½-year-old group visit, where we focus on the child’s social and emotional development with a group of providers, caregivers, and patients.

Because immunizations keep children and communities well, we are working to check at every visit to see if a child needs immunizations — and give them if they are missing.