By Iliana White, MPH, CHES, CPH
Senior Program Manager, Adolescent Health, AMCHP
Quality improvement (QI) can be a loaded term, and operationalizing it within Title V efforts can seem intimidating. But efforts to improve the quality of health care for adolescents and young adults at one New Mexico clinic show how making small, incremental steps – a core characteristic of QI – can build a foundation for grander improvements to be scaled and spread.
First, some background: New Mexico has a long history of serving youth through its network of school-based health centers (SBHCs). The state Office of School and Adolescent Health (OSAH) in the Department of Health guides policy development on school and adolescent health issues and is involved in workforce development and training for those providing services to youth. In addition, OSAH has a close working partnership with Envision New Mexico, a child health care quality initiative based at the University of New Mexico Department of Pediatrics. For over a decade, the SBHCs across the state took part in QI initiatives focused on preventive services, including one that examined the quality of comprehensive well-exams in the clinics. Rates of receipt of the well-visits in SBHCs were compared with other statewide measures, and medical record reviews were conducted to verify quality indicators within those visits. SBHCs are viable access points for health care among youth, and the adolescent well-visit was found to be the main reason students access services at the centers.
Fast forward to 2015, when New Mexico was one of five states selected to participate in the Adolescent and Young Adult Health (AYAH) CoIIN, funded by the U.S. Maternal and Child Health Bureau and supported through the AYAH National Resource Center. In its approach to improve access to and quality of preventive services, the New Mexico team sought to scale the QI process that improved its SBHCs to other clinical settings in outlying communities. The rationale was that although the care within the SBHCs was youth-friendly and centered toward the needs of adolescents, this was not evident for young adults once they matured out of the school system. In addition, research shows that young people are less likely to get annual, preventive well-visits after they age out of their adolescent years. Lead by a multidisciplinary team of Title V leaders, youth advocates and leaders, Envision New Mexico staff, providers, community partners, the CoIIN team selected El Centro Family Health to help replicate the quality and successful strategies employed in the SBHCs at El Centro’s other clinics. El Centro is a federally qualified health center that serves eight counties and operates nine SBHCs as well as other community sites.
Why El Centro? Yolanda Montoya-Cordova, the former director of OSAH, said El Centro was selected because it had been part of previous QI initiatives and was an early adopter of QI in its SBHCs. In addition, El Centro’s leadership, including its medical director, was willing to try to test the successes from the SBHC QI efforts at a communitybased El Centro clinic, in the Las Vegas, N. Mex., area. Data from that clinic showed that the receipt of the well-visits there were below the rates at the SBHCs; this provided an opportunity to implement the QI process.
In the community sites, the CoIIN team discovered that one area for improvement was the readiness of the providers to receive older adolescent and young adult patients. The providers revealed that they were not as confident or trained to deliver services with the AYAH focus. As a result of this revelation, the SBHC team trained the other clinical staff in these sites on components of youth engagement as well as how to ensure that their delivery of services is youth friendly. “We basically taught them how to fish,” Cordova said. “Intentionality around quality improvement is what made the difference.”
The buy-in, training and capacity-building of providers in the community sites were successes that served as a small milestone in the move toward bringing the quality of AYA health care in schools to e other settings. Also, comprehensive well-exams for AYAs will be adopted as a performance measure across the clinical system, not just in the SBHCs that El Centro operates.
The AYAH CoIIN efforts will continue to bring new changes, but this early stage of small achievements can have influence beyond the participating sites: It shows youth accessing preventive services even after they mature out of the school, and that the care they receive is built around their physical, emotional and developmental needs. Cordova hopes other clinical systems serving AYAs in the state will notice El Centro’s lead on this effort and follow suit, like a friendly competition.
Several factors helped El Centro’s CoIIN team get to this point of the process, Cordova says. The established partnership with Envision New Mexico provided the foundation for adolescent health to be a top priority among health care providers and clinical systems prior to the AYAH CoIIN; El Centro’s onsite coaching, web-based training series and technical assistance helped accelerate efforts in previous QI projects. She also emphasizes how the trust and rapport between the OSAH and El Centro Family Health was essential to buy-in among staff, and that data found within medical record reviews was extremely helpful in understanding where improvements could be made and how to look at incremental progress.
Cordova recommends that Plan-Do-Study-Act (PDSA) cycles (which are pillars of QI) be brief yet meaningful in the approach. Also, this QI effort – as well as others that may come along – will require a shift in focus among providers and youth to better understand the power of prevention. This milestone with the CoIIN might seem like a small step, but it can influence more significant and broader improvements for AYA patients to be made across the El Centro Family Health system – and, it is hoped, across other systems in the state.