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Reaching Out to Rural Practices in Tennessee

Thursday, February 21, 2019 - 11:00

As a Pediatric Portfolio Sponsor with the ABP, the Tennessee Chapter of the American Academy of Pediatrics (TNAAP) approves quality improvement (QI) projects for Maintenance of Certification (MOC) Part 4 credit. But unlike many Portfolio Sponsors that work solely in hospitals in large urban areas, TNAAP also focuses on primary care settings in small towns across the state through its Pediatric Healthcare Improvement Initiative for Tennessee (PHiiT) and other programs. This is the story of one such practice.

Dr. Amy Evans with a young patient

As part of her medical school training in the 1980s, Amy Evans, MD, traveled to Santiago, Chile, to examine the differences between urban and rural health care. Now a general pediatrician in a small-town private practice in Sewanee, TN, dozens of miles away from the closest medical school or large medical center, she understands firsthand the challenges of providing rural health care.

“When I first came to Sewanee in 1994, there was not a pediatric practice,” says Dr. Evans, founder of Sewanee Pediatrics and Adolescent Medicine. “And although Sewanee is a small university town, most of our patients come from rural Grundy County — the poorest county in Tennessee and one of the poorest in the United States. Sixty percent of our patients are covered by Medicaid.”

According to the U.S.Census Bureau, nearly 23 percent of the Grundy County population of 13,000 live in poverty, and the median household income in 2016 was less than $29,000.1

To improve the care provided to her patients and distinguish the practice from nearby urgent care facilities, Dr. Evans called the TNAAP a few years ago for help. She wanted the practice to become a recognized National Committee for Quality Assurance (NCQA) Patient-Centered Medical Home (PCMH).

Becky Brumley“At the time, PCMH standards were getting ready to change,” says Becky Brumley, MPH, PHiiT Program Director and Quality Coach. “So instead, the practice started with PHiiT, which then catapulted them into becoming a medical home because PHiiT focuses on building the QI infrastructure that is a large part of PCMH.”

“The first thing Becky did was set up our team,” says Dr. Evans. “Then they taught us how to do a PDSA [plan, do, study, act] cycle, which is so empowering. They helped us ask the right questions and collect the appropriate data.”

After on-site QI training, the practice started the early well-care project in October 2016. Subsequently, the practice completed PHiiT’s asthma project, completed a second well-child project, and started the adolescent health project.

“We had more success than we expected,” says Dr. Evans. In March 2018, 65.7 percent of their active patients were up to date on physicals. “Now when they come in sick, we try to do a well-child check, too.” By October, the percentage of patients up to date on physicals rose to 76.3 percent.

Sewanee Pediatrics and Adolescent Medicine, now an NCQA-recognized PCMH, is one of 50 practices and four residency programs across Tennessee currently enrolled in PHiiT projects, which also include breastfeeding sustainment, tobacco exposure reduction, behavioral health, and HPV vaccinations. In addition to QI training at their practice, participants receive access to educational videos approved for CME credit, coaching, monthly support calls, aggregated data from other practices, a data collection system, personalized reports, and tools like flyers, handouts, posters, and measures tables. More than 100 pediatricians have received MOC Part 4 credit since 2015, and the number grows every year.

“The monthly support call is the best 30 minutes I spend every month,” says Dr. Evans. “We plan to stay in PHiiT for as long as it is available!”

Dr. Mary Heath with a young patientMary Heath, MD, MPH, also a pediatrician at Sewanee Pediatrics and Adolescent Medicine, says quality improvement has been very helpful for the practice. “It has engaged our staff in a different way and made an impact in our community as we help families, who are busy and stretched, stay on task,” she says. “QI work helps us all stay on track.”

Dr. Allen CoffmanAllen Coffman Jr., MD, concurs that one of PHiiT’s goals was to put pediatricians and parents back in the driver’s seat. As the former TNAAP President and Medical Director of PHiiT, he envisioned the program, led its development with support from the National Improvement Partnership Network (NIPN), and was instrumental in designing the projects. “Pediatricians can solve the problems and frustrations they have about primary care if they are given the right tools,” he says. “The participating practices are doing amazing work in a very short period of time.”

Dr. Evans says that beyond quality improvement in individual practices, TNAAP is trying to raise the bar about what primary care is. “Primary care is often not valued because it’s not based on medical procedures. If all AAP chapters had a project like this, it could be a way of sustaining and improving pediatric primary care across the country.”

1United States Census Bureau. QuickFacts: Grundy County, Tennessee. Accessed February 1, 2019.