Improving the Care of Newly Arrived Immigrant Patients in Two Primary Care Clinics

ABSTRACT

Purpose/Objectives: 1) To design and implement a clinical pathway that delineates evidence-based recommendations of screening for newly arrived immigrant children in an academic primary care setting. 2) To improve adherence to recommended biomedical and infectious screening by providers caring for newly arrived immigrant children. 3) To evaluate the effectiveness of the clinical pathway and adjunct tools to support uptake and adherence to the pathway with a goal of achieving 90% adherence to key indicators in 18 months. Design/Methods: A clinical pathway for primary care of newly arrived immigrant children was developed and implemented based on existing evidence from immigrant and refugee populations, delineating recommended psychosocial, developmental, biomedical, and infectious screenings by region of origin. Adjuncts to support uptake were implemented, including an EMR order-set and note template. Faculty and resident education to the pathway was conducted in person and with pre-recorded educational presentations. Indicators of adherence were defined as the percentage of patients who obtained the recommended screening tests according to their world region of origin. Results: A total of 301 newly arrived immigrant patients were seen at the clinics during our observation period (from Dec 2018-May 2021);190 (63%) were seen after the rollout of our main interventions in August 2019, and 70 (23%) were seen after the onset of the COVID-19 pandemic in March 2020. We observed an improvement in the % of patients who obtained lead level, Complete Blood Count (CBC) with differential, Strongyloides, and Tuberculosis screening on their first visit in the U.S. following the introduction of the clinical pathway and order-set (Images 1 and 2). There have been six consecutive points above the mean in the case of lead level and Tuberculosis screening. In the case of Strongyloides screening, a mean shift was observed months after the implementation of the pathway. On average, 74% of the ordered screening tests for these patients were entered using the order-set. The COVID-19 pandemic impacted the number of new patients in both clinics from April 2020-Sep 2020. Periodical reminders and continuous education to providers also have proved beneficial to our goals. Conclusion/Discussion: Implementation of a clinical pathway for the care of newly arrived immigrant children resulted in improvements in adherence to region-specific recommendations for biomedical and infectious screenings;specifically for lead, CBC with differential, Strongyloides, and Tuberculosis screening. Implementation of an order-set embedded in the electronic medical records system was a successful strategy to facilitate adherence. Drastic reductions in the number of new immigrant children seeking care during the initial months of the COVID-19 pandemic raised concerns about access barriers for this vulnerable population and required strategies to remind clinicians about the use of the pathway as numbers of new immigrant patients return to baseline.