Helping Kids Keep Their Same Provider

Children who visit the same primary care provider over time have better experiences with the health care system and improved health outcomes. Families are happier with the care that their children receive, children are more likely to be up-to-date with preventive care and are less likely to need to go to urgent care centers or the emergency department. 

Having a usual primary care provider is a key component of the medical home, a place where children can have comprehensive and coordinated health care. 

But for decades, the goal of patient-provider continuity in primary care has largely been abandoned in large academic medical centers, said Dane Snyder, MD, section chief of Primary Care Pediatrics at Nationwide Children’s Hospital. Academic center providers have institutional responsibilities beyond seeing patients, including administration, research, and training residents and fellows. It can be difficult to schedule a patient’s preferred provider.

That was certainly true at Nationwide Children’s, which has more than 120,000 primary care patients, most of whom are covered by Medicaid.

“The focus was on health care access – making sure a patient could get in to be seen – at the expense of continuity,” Dr. Snyder says. “If you focus only on access instead of making sure that children can see their usual primary care provider, you lose the opportunity to focus on continuity, which can have a negative impact on the quality of care. It’s an equity issue. A patient in a private practice expects to see the same provider. We should make that happen for our patients too.”

In 2017, there was little continuity in primary care well-child visits at Nationwide Children’s, mirroring the situation across the country. Patients saw any available primary care provider, not necessarily one they knew and had built trust with.

But after seven years of concerted effort led by Dr. Snyder and his colleagues, the continuity rate in Primary Care Pediatrics at Nationwide Children’s is 72%, the highest reported rate among academic medical centers in the United States.

The continuity project was also associated with an increase in preventive care visit completion rates from about 53% to about 61%, a reduced rate of missed appointments for preventive care from about 25% to 20%, and a 20% reduction in emergency department visits.

It also just made patients, families, and the whole care team happier, said Dr. Snyder.

“As pediatric providers, we get into the profession wanting long-term relationships with parents and families so we can help improve their health,” he said. “It makes the job more enjoyable. Families develop trust with us. We have seen all of that during this process.”

Dr. Snyder and his colleagues published a study in 2022 detailing their steps toward more continuity, which have continued and expanded since then.

Among the most important ones:

• Empanelling, or assigning, patients to a primary care provider and a primary resident. Families were given the option of choosing a provider they already knew.
• Reducing sessions of providers “floating” to other offices to cover shifts.
• Scheduling the next well-child visit during the check-in process for the current visit when the child is 15 months of age or younger, because of the many recommended well-child visits during the first two years of life.
• Creating new rules for appointment scheduling that promoted continuity, such as only scheduling an appointment with a different provider when family timing needs couldn’t be met with the preferred provider
• Allowing online patient scheduling for preferred providers, and sending electronic messages when well-child visits were due

With these efforts, the continuity rate jumped to 50% in 2022 and with newer tools like the introduction of a wait list for well-child visits, the continuity rate was boosted to its current level of 72%.

The goal is not to have the continuity rate be 100%, because the hospital wants to make sure that patients have easy access to our clinics, and sometimes the preferred providers are not available, says Dr. Snyder. The focus on continuity is for preventive care, where the timing of need can be predicted far in advance. The same kind of continuity is not possible for children who are sick and who must be seen within 24 hours.

Dr. Snyder says that the efforts to increase continuity will continue, with a potential of reaching of 80%, but only if that means that that families get the care they need, when they need it.

“Now that Nationwide Children’s has shown that this kind of continuity is possible, other hospitals are coming to us to learn more,” said Dr. Snyder. “It is exciting to become a national model, but at the end of the day, it is great to be able to improve the care that children and their families receive at Nationwide Children’s.”

Published May 2024