4 Smartphones for Nurse Mobility

Smartphones have the potential to transform workflows for nurses and other hospital caregivers. Rather than carrying around multiple devices, smartphones give clinicians mobile access to the EMR, integration with nurse call and telemetry, and secure medical communication and collaboration.

PerfectServe has partnered with many clients in their transition toward mobility with smartphones to enhance clinical collaboration. We want to use this experience to help other health systems in the journey. 

The first question we hear about mobilizing care team communication is usually, “Which device should we buy?” and the answer is always, “It depends.”   

No one device has emerged as the clear best choice across the board, but we are happy to share some top contenders and key considerations for health systems evaluating mobile devices.

Zebra Technologies TC52-HC¹ 

Zebra has been in the healthcare space for years, with their MC40 mobile computers and broad range of solutions like printers, scanners, and kiosks. A few years ago, they introduced the TC51-HC and quickly followed it up with the evolved TC52-HC.

The TC52-HC is a healthcare-focused unit that offers strong hardware performance and support for modern versions of Android. The device is protected by a rugged exterior that’s built to survive day to day in a nursing unit.  

As an enterprise device, the TC52-HC is available with built-in telephony, barcode scanning, robust battery capabilities, and many more features that come in handy in a healthcare setting. Like the other purpose-built Android devices on our list, the TC52-HC is a hardened device that can withstand repeated drops, exposure to liquids, and frequent exposure to healthcare disinfectants.

Improving upon the TC51-HC, the TC52-HC offers an additional microphone, advanced noise cancellation, and a louder speaker to hear and be heard in noisy environments. Its battery is the largest of our recommended devices, and Zebra includes software tools that ensure the battery will last through an entire 12-hour shift.

Why buy it: Long-Term Quality  

Zebra and its partner network are well established in healthcare, offering plenty of resources to help your project succeed. Zebra made sure the TC52-HC is backwards compatible with TC51-HC accessories and future-proofed the device through Android 10 and later.  

Honorable Mention: TC21-HC

Zebra also recently introduced a new TC21-HC device, targeted at ancillary healthcare workers like environmental services, transport, and food service staff. The TC21-HC offers most of the same features as the TC52-HC in a slightly smaller, more cost-effective package.

Apple iPhone SE²

This device needs no introduction.  

As a consumer-grade device, the iPhone delivers leading-edge hardware and software wrapped in a small, sleek package.  

Compared to most enterprise-specific devices, an iPhone SE is a low-cost option. However, as a consumer phone, the Apple device will not offer the ruggedness, battery capabilities, native IP telephony, and other enterprise-grade features. Third-party protective sleds and charging solutions are available to make the device hospital ready.

The low cost, form factor, and familiarity of the iPhone make it a good option in the current device market.

Why buy it: iOS

If your organization prefers the Apple mobile operating system, your device choice is clear. 

Spectralink Versity³ 

Spectralink has years of experience providing voice handsets that run on hospital wireless networks. After entering the smartphone market in 2014 with the Pivot, Spectralink rolled out the Versity to customers in late 2018.

Looking at the spec sheet, the Versity checks all the boxes for ruggedness, battery, telephony, etc. Its hardware and Android 8 operating system raised the bar in the enterprise device market.  

Spectralink emphasizes voice quality with the Versity, leveraging years of wireless handset experience and advanced audio processing software. The device is available with a scanner or without for a sleeker, lower-cost option.

Why buy it: Form Factor  

The Versity is slim and light, as close as you will find to a consumer phone in a rugged package. 

Ascom Myco⁴ 

Another company with deep healthcare experience, Ascom offers the Myco 3 smartphone alongside its wireless telephone and nurse call products. Although the Myco 2 received mixed reviews, the new Ascom Myco 3 (launched in 2019) shows great potential as a nursing device. The five-inch screen, battery, ruggedness, and operating system are all in line with the Zebra and Spectralink devices.

Ascom has followed a more traditional smartphone form factor with the Myco 3, but they have added some creative functional touches. The device includes a removable clip to attach to a waistband or pocket. When worn clipped to scrubs, the top edge features multi-color LEDs that supported apps can use to signal informative notifications. The dedicated barcode scanner is on the rear, rather than the top, so users can see the screen easily while they point the scanner.

The Myco 3 is the newest device on this list. We had great results testing the device in our certification lab, and now we look forward to real-world feedback from our customers.

Why buy it: The Ascom Touch  

Health systems already using Ascom nurse call and wireless phones should certainly consider the Myco 3 mobile device, along with any other team that could benefit from its unique ergonomic design.

Conclusion

This is an exciting time as manufacturers continue to bring improved smartphones to the market. PerfectServe is here to share our experience and help you achieve your goals for clinical communication.  

If you want more information about nurse mobility, click below to book a call with a clinical communication specialist.  

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PerfectServe Stands in the Fight Against Racism and Injustice

The murder of George Floyd on May 25—and the events that have transpired since then—requires deliberate introspection about the state of affairs in our country and beyond. These events are of deep concern to me, our employees, our families, our friends, and our communities.

The Black community is in pain, and positive change is a necessity. PerfectServe stands in the fight against racism and injustice. We stand to overcome the challenges that we face and use our voices to demand that ignorance and inequity come to an end.

It’s important for me to reassert that PerfectServe has zero tolerance for discrimination of any kind. We pride ourselves on creating a work environment that is equally welcoming to people of all races, genders, religions, sexual orientations, ethnicities, and nationalities.

In this moment, actions speak louder than words. We’re committed to evaluating our processes and standards—with help and input from people inside and outside the company—to ensure that diversity and inclusion play a larger role in PerfectServe’s culture moving forward. Change doesn’t happen overnight, but these initiatives will make us a stronger company and a better member of the community in the end.

This is only the beginning. We are confronted with daunting social challenges, and there isn’t a silver bullet. We can all do better, and PerfectServe is committed to being part of the solution.

Guillaume Castel
CEO, PerfectServe

National Nurses Week 2020

Annual celebration of nurses takes on special meaning during COVID-19 pandemic.

This week, businesses around the country, from Dunkin’ to Adidas to Chipotle to H&R Block, are clamoring to offer freebies and discounts for nurses to celebrate National Nurses Week 2020. Though it’s never a bad time to highlight the incredible work nurses do as vital members of care teams in healthcare organizations across the country, this year’s celebration feels especially poignant as the country (and much of the world) is still reeling from the effects of COVID-19.

PerfectServe is fortunate to have nurses on staff, including team members who still practice part-time today and others who transitioned into information technology full-time after spending years in nursing careers. With this valuable perspective in-house, we asked a few of these current and former nurses to share their thoughts about how COVID-19 has changed the role of a nurse, and which we’ll share throughout the rest of the week.

Julie Mills, RN, BSN, MBA

With 18 years of experience as a nurse, Julie has worked in many capacities sharing her clinical expertise, including in the US Air Force as a Unit Coordinator. Currently, Julie is a Senior Clinical Solutions Executive at PerfectServe, where she serves as a clinical advisor to teams across the company. She also practices at the University of Tennessee Medical Center and is pursuing her Doctor of Nursing Practice in Healthcare Administration degree at the University of Tennessee at Chattanooga.

Nurses are the listening ear, the conversationalist, and the hand holder.

“I’ve been a nurse for 18 years and currently practice a few days every month at an academic medical center that also serves as the region’s only Level I Trauma Center. COVID-19 brings a heightened sense of awareness to all that we do—checking temps when you walk in the door, wearing masks, and being mindful of supplies. Families aren’t allowed to visit, so they’re calling us more for updates about their loved ones, and the emotional support we provide becomes more critical to the patient.

Nurses have always been the primary patient caregiver at the bedside, but in a crisis, their role is expanded. Without families at the bedside, the nurse is the all day, everyday support system. Beyond providing care, nurses also step up to be the listening ear, the conversationalist and the hand holder. In rapidly changing clinical situations, the nurse’s clinical acumen and intuition are essential to managing care and communications with other team members.”

Mary Piepenbrink, RN, BSN, MBA

With more than 25 years of experience in the healthcare industry, Mary has served both as a nurse and a leader in information technology software and service solutions. Currently, she is the Vice President of Sales, Lightning Bolt, where she supports caregivers and helps hospitals and health systems improve their operations, reduce costs, and counteract provider burnout.

COVID-19: An Unprecedented Situation for Nurses

“This is unprecedented for most nurses; most do not have experience beyond routine infection prevention standards and practices. Some specialists mask, gown, and glove up when they care for known infectious patients, but typically that is a careful, thoughtful, measured approach. With COVID-19, nurses are doing this in long stretches and seeing patients rapid-fire. Nurses aren’t just concerned about the hard mental and physical work caring for patients they they normally do—they are fearful about transmission to other patients, concerned about the health of their coworkers, and of course have enormous stress about bringing the virus home to their families. As they do what they do best—triage, adapt, multitask, worry—I can’t but help wonder what effect this will have on our profession long term. I check in on my clinician friends—nurses, doctors, pharmacists—not just where I live, but in other more affected cities, to try and support them by listening and providing encouragement. Many of us feel helpless to do more.”

Mark Denny, BSN

Currently a Clinical Consultant at PerfectServe, Mark assists healthcare organizations as they implement PerfectServe’s Clinical Communication & Collaboration solutions. Mark worked in clinical informatics before transitioning to healthcare IT consulting.

Much-Needed Recognition for Nurses

“The presence of a nurse has a critical impact in any clinical setting, but even more so at this time. Right now, nurses are truly practicing the emergency alert responses they are taught and hope to never use. Nurses in general are frequently exposed to pathogens, bugs, volatile patient situations, staff shortages, and endless documentation, all the while going unnoticed for their work on a day to day basis. This crisis has brought to light many of the dangerous situations nurses willingly walk into every day, and they are now receiving the recognition they deserve. My work doesn’t take me to the bedside anymore, but my contributions make it easier for nursing staff to communicate with their co-workers and on-call physicians while making a positive impact on patient care.”

Celebrating National Nurses Week

For over 20 years, PerfectServe has worked hand-in-hand with nurses to improve care delivery workflows at hospitals and practices across the country. In fact, PerfectServe might not exist if it hadn’t been for the wife of founder Terry Edwards. Penny Edwards was a nurse handling inbound communication for a private practice, and her frustrations with the antiquated process for fielding patient messages and coordinating responses with the physician are what led Terry to devise a more modern after-hours answering service solution.

From those beginnings, PerfectServe has grown to serve healthcare delivery organizations of all shapes and sizes, and one thing that has never changed is the courage and dedication we witness every day from the nurses we serve. Happy National Nurses Week, and thank you for being the backbone of care delivery in communities throughout the United States, especially in times of crisis.

3 Ways to Save Nurses’ Time With Better Communication

Nurses play a central role in providing patient-centered, cost-effective care. They are responsible for care coordination and communication with each patient’s family members, as well as a growing care team of physicians and specialists, ancillary staff, and care coordinators. In addition to nurses’ growing list of daily nonclinical tasks, inefficient care coordination workflows prevent them from working to the top of their licensure.

A 2018 time and motion study revealed that in four hours, nurses spent around 32 minutes communicating with patients and family and 51 minutes communicating and coordinating care with members of the care team¹—fully 34.6% of nurses’ time each day. Technology aimed at improving nurse workflows has often contributed to their frustration by adding siloed, task-specific “solutions” to their workload.

Let’s talk about the alternative. Keep reading to learn three ways clinical communication and collaboration (CC&C) technology can help healthcare organizations empower their nurses to work at the top of their license to drive patient-centered care for optimal outcomes.

Reduce Communication Cycle Times

Communication workflows are often cumbersome, requiring nurses to reference several systems and/or paper on-call schedules to page, call, and relay information through office staff … and then wait for the intended recipient to call back. This error-prone process causes care delays and requires a full restart when a provider is unavailable for any reason.

An improved communication strategy built around an integrated solution like PerfectServe can reduce average response times from 45 minutes to 20 minutes or less.² Here are some key capabilities that can make it easy for nurses to find the right physician at the right time:

• One unified directory to find and contact clinicians by name, role, and/or on-call status (e.g. “cardiologist on call”), or to send messages to the whole patient care team at the touch of a button.
• Built in physician contact preferences to ensure communication is delivered via the preferred/frequently checked method.
• Read receipts and smart escalation to ensure messages are read, acknowledged, and acted upon in a timely manner.
• Message history and EHR integration for quick context.

Faster communication leads to safer, quicker, and higher quality care.

Integrate Alerts and Critical Result Notifications

Alarms, alerts, and other notifications continue to be named among the top 10 health technology hazards for 2020,³ impacting patient satisfaction and contributing to alarm fatigue.

In a 2015 study, nurses reported that only 52% of bed calls required nursing care, while others could be answered by support staff.⁴ Constant interruptions reduce care efficiency and require nurses to make multiple unnecessary trips to patient rooms. While nurses are inundated with too many alerts, they are not adequately alerted of critical results and orders, requiring them to repeatedly check the EHR for updates.

Centralizing alerts and communication across multiple systems, including the EHR and nurse call system, can eliminate noise, add context to alert notifications, and call attention to critical alerts by allowing:

• Delivery of alerts to mobile devices, where nurses can accept, escalate, or call back to speak with the patient.
• Push notification of critical results (lab or radiology) or physician orders to speed up time to care.
• Routing of nonclinical alerts to patient care techs or nursing assistants.
• Workflow rules to help ensure that only critical alarms disrupt normal workflows and are differentiated with a distinct alert tone.
• Clinical surveillance to send push alerts for sepsis, respiratory deterioration, organ failure, etc.
• Routing of “leads off” alarms to only alert the nurse assigned to that specific patient, set to escalate to the charge nurse if the assigned nurse does not respond within a predetermined time frame, eliminating an audible, ward-wide alert.

Simplify Patient Engagement

Nurses are tasked with keeping family members up to date on patient status, sharing care instructions, arranging discharge, and following up with patients and their families after discharge. As nurses invest increasing amounts of time in patient and family engagement activities, they become more confined to the nurses’ station and less available at the patient bedside.

Post-discharge patient engagement often relies heavily on phone communication, with declining impact due to phone tag and low voicemail retrieval rates. On the other hand, secure texting with patients and families allows health systems to automate more effective outreach in order to:

• Share care instructions, arrange discharge, and answer questions.
• Route inbound messages to the call center, rather than the nurse, for triage.
• Automate patient outreach, such as surveys, post-discharge instructions (tailored to the patient profile), and referrals.
• Support two-way communication and allow individuals to respond to patients as needed, leveraging the expertise of nurse assistants, call agents, and more.

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PerfectServe’s CC&C solution with patient engagement capabilities helps streamline nurse workflows, reduce care delays, improve patient safety, and boost patient satisfaction. To learn more, contact us or click below.

PerfectServe’s Solution for Nurses

Preventing Patient Leakage With In-Network Referrals

In the shift to a value-based care model, healthcare organizations must deliver cost-effective, quality outcomes across the spectrum of care to individual patients and patient populations. To succeed under value-based care and programs such as the Affordable Care Act (ACA) and the Medicare Access and CHIP Reauthorization Act (MACRA), health systems have begun to consolidate. Consolidation allows healthcare networks to leverage technology innovation, share risk, improve care coordination, and offer greater patient access to clinical services.

With the rise of large healthcare systems made up of hospitals, primary care facilities, outpatient facilities, and ancillary services comes the opportunity to create a greater care team of providers from multiple facilities to support patient and population health efforts. Large healthcare systems are working to improve care coordination, reduce duplicate testing in the referral process, and create a system to support improved patient outcomes.

Patient leakage—when a patient seeks or obtains services outside the hospital network—makes it difficult to track and support patient outcomes. The onus is on healthcare leaders to reduce patient leakage to support value-based care.

The Cost of Patient Leakage

Every year, more than a third of patients in the US are referred to a specialist. Healthcare executives report the following:

• 43% say they are losing 10% or more of annual revenue to patient leakage.
• 19% say they are losing up to 20% of revenues.
• 20% say they don’t understand where or why patient leakage occurs.
• 23% of organizations neither track nor quantify patient leakage.¹

Not only does patient leakage lead to lost revenue and increased coordination costs for the health system, it can also have negative impacts on the patient. With fragmented coordination outside of network, some specialists may not have full access to the patient’s medical records and history to support the referral.

One study found that approximately 70% of primary care providers (PCPs) reported sending patient history and reason for referral, but less than 35% of specialists report receiving that information.² Inefficiencies in the referral process can result in denied referrals, delays in patient diagnosis or care, duplicate testing, and reduced continuity of care.³

20% of malpractice claims for missed or delayed diagnoses involved communication deficits in handoffs.³

Patient leakage occurs for a variety of reasons, but it happens most frequently when physicians refer out-of-network. While relationships may be one cause of these referrals, one study found that 80% of out-of-network referrals in a 700-physician medical group were attributed to a lack of understanding of the Accountable Care Organization (ACO) network.⁴ Making it easier to find in-network care providers helps health systems provide coordinated patient care.

Patient Satisfaction Contributes to Patient Leakage

On one side, healthcare organizations can reduce business losses from out-of-network referrals and improve care outcomes by making it easier to find and hand off care to in-network care providers. The second side of patient leakage is when patients choose to leave the healthcare network, which could be due to a lack of information about in-network options or issues with patient satisfaction.

With patients now assuming greater financial responsibility for their care, and the consumerization of medicine in general, patients may walk away with a referral but then choose a competing facility. It sometimes happens because the patient is dissatisfied with their current care or simply because, through research or reviews, they choose a competing facility with little awareness of the impact the choice will have on the coordination of their care plan.

Optimize Communication to Reduce Patient Leakage

To reduce patient leakage, healthcare organizations need to support in-network referrals and help ensure the right information is communicated to the right care provider at the right time. A clinical communication and collaboration (CC&C) solution can help with:

• Unified Directory – Easily look up any member of the care team by name or by role. Referring physicians can look up a “cardiologist” to see a list of in-network cardiologists, with the opportunity to further refine the list by hospital or healthcare facility to best support patients.
• Safe Patient Handoff – Referring PCPs or hospital physicians can perform a safe handoff to seamlessly share patient history and clinical notes with the specialist.
• Coordinated Care – Support ongoing communication among the care team to foster team-based decision making and close the loop on the care plan.
• Patient Referral Follow-Up – After discharge or referral, an automated message can be sent to patients to connect them with an in-network provider (if not already specified) to schedule an appointment and help increase the completion rate of referrals.
• Patient Satisfaction Surveys – Surveys after each healthcare encounter can help organizations spot and potentially recover from dissatisfaction that can impact patient loyalty.

By focusing on reducing patient leakage, healthcare networks can help realize their value-based goals. To learn how to help support coordinated care and reduce leakage, contact us for a demo.

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The Role of Patient Engagement in Remote Patient Monitoring

Remote patient monitoring (RPM) allows healthcare providers to monitor patients outside of the clinical setting. Particularly important for the management of chronic diseases, RPM is helping improve patient outcomes and reduce healthcare delivery costs.

Why Patient Monitoring is Critical

It is important to remember that patient monitoring is essential, especially when it comes to combating chronic diseases. By 2020, it is estimated that more than 40% of all the adults in the US (roughly 157 million people) will suffer from at least one chronic health issue such as diabetes or asthma; almost a quarter (81 million) will live with multiple chronic conditions.¹

One of the best ways to treat chronic conditions is with regular and consistent treatment. However, the average American struggles with care plan adherence. Roughly half of all-American patients do not take their medication as intended; one out of five prescriptions are never actually filled. Medication non-adherence is estimated to cause 125,000 deaths per year. Poor medication adherence results in 33-69% of medication-related hospital admissions, with medication nonadherence costing the industry as much as $300 billion in direct and indirect costs every year.²

As of 2019, the Medicare fee schedule attaches reimbursement to general physiological remote monitoring of chronic conditions. This new schedule recognizes the value of patient-reported outcomes and RPM in improving health outcomes and reducing healthcare costs. According to KLAS Research, one-fourth of healthcare organizations say RPM reduces emergency visits and readmissions.³ Further, 13% of organizations report RPM improves medication compliance, 17% cite quantified cost reductions, and 25% report greater patient satisfaction.⁴

To effectively treat chronic illnesses, patients must adhere to a strict treatment regimen: taking their medications as prescribed and regularly attending follow-up appointments. As well as being a waste of clinical resources, a patient’s failure to attend their scheduled appointments (no-shows) often can be an early warning sign of care plan non-adherence.

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Text-First Approach to Patient Monitoring

Using cancer clinics as an example, many implementations of RPM and patient-reported outcome systems are tied to in-clinic appointments or discharge, but not all include routine outreach.⁵ In other instances, self-reporting RPM systems may be cost-prohibitive or lack integration with the hospital infrastructure required to support clinical workflow.

Healthcare organizations can leverage text messaging to collect data for remote patient monitoring and gather patient reported outcomes with simple surveys. Healthcare organizations can text a link to a secure web survey to assess wellness, pain levels, specific measures (e.g. blood glucose levels), or potential medication side effects.

Other clinical communication modalities are not as effective or efficient. Only 20% of emails are opened.  Patient calls from the clinical staff have a very high administrative cost. In comparison, text messaging is extremely quick to administer and 90% are read within 3 minutes of being sent.⁶

PerfectServe’s text-first patient engagement solution can automate the collection of RPM data and other patient-reported outcomes. Survey responses that pass a predefined threshold are automatically escalated to expedite early intervention. All messages support two-way text messaging with healthcare professionals and the option to invite patients into an encrypted channel for secure chat. PerfectServe customers report:

• 70% ongoing response rate for patient health status
• 0.9 point reduction in A1C
• 12.6% reduction in no-show rate
• 32% reduction in readmissions

Empowering patients to participate in remote monitoring activities improves patient care plan adherence and patient satisfaction alike. The net result improves outcomes and reduces costs.

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Improve Well-Child Schedule Adherence with Patient Engagement

The medical system has long adhered to the tenets of value-based care in the establishment of the periodicity schedule for well-child visits. The American Academy for Pediatrics (AAP) recommends formal screening for infants through adolescence to chart growth and development and to provide early interventions for illnesses and injuries, which provides benefit to both children and the healthcare system as a whole.

“While the end goal of health transformation should be achieving the triple aim of improved health quality, improved population health, and reduced per capita health care costs, this requires investing more, rather than less, in primary, preventive, and developmental care. At no age is this truer than for children, whose health trajectories have health cost implications over decades and lifetimes.” – Charles Bruner, Ph. D., et al¹

Unfortunately, adherence the well-child schedule is suboptimal, with rates diminishing over time – as low as 41% by the time the child is 15 months old.² For children over age 6, well-child visits help ensure continued health, including assessments on growth, weight, sleep, or signs of physical or mental health issues.³ For children with chronic conditions such as asthma, evidence suggests that low well-child visit adherence rates are associated with an increased risk of hospitalizations.⁴

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The reasons behind low adherence rates are complex. Modern families face multiple time constraints, may not know about ongoing well-child visit needs, or may face social or economic challenges that impact their ability to adhere to the periodicity schedule. Pediatric professionals focusing on improving adherence to well-child visits can take a multi-pronged approach:

• Well-Child Visit Reminders: encourage adherence to well-child schedule with automated reminders or suggested appointment timeslots
• Social Determinants of Health: focus health promotion materials on family, community, and social factors, including links to community resources, transportation coupons, etc.
• Pre-Appointment: send appointment reminders and preparation instructions, helping reduce no-show rates
• Lower Readmissions: follow up with children recently released from hospital after injury or illness with automated assessment questionnaires and care plan reminders
• Wellness Education: provide pro-active wellness information and links to appropriate community resources or educational material on your patient portal.
• Chronic Condition Management: identify and track children with special health care needs, sending care plan reminders, ongoing encouragement, and periodic assessment questionnaires to parents to expedite intervention

PerfectServe can provide you pre-scheduled communications as well as two-way messaging to help engage patients and their families in positive health outcomes. PerfectServe’s Patient & Family Communication tool leverages SMS text messages, social determinants of health, and pre-populated workflows to identify patients and families who could benefit from well-child visit reminders, educational materials, or SDOH support. Unlike emails or phone calls, text message communications benefit from high response rates, allowing you to reach out to parents when and where it matters most. Parents can schedule an upcoming well-child visit, answer a wellness survey, or ask a question, with automatic alerts sent to the care team if a patient may need preventative support or outreach.

Working with one of the nation’s largest healthcare systems, we sought to improve well-child schedule adherence rates for children age 0-3 years old. Prior to the program, many well-child visits occurred up to a month after they should have, impacting immunization schedules and early prevention programs. PerfectServe’s Patient & Family Communication tool sent parents a reminder about well-child appointments, leading to 13% more pediatric well-child visits, a tighter adherence to the recommended schedule, and more participation in visits beyond infancy. The program had the benefit of also raising postpartum depression screening rates from 30% to 70%.

Contact us to learn how we can help improve your well-child initiatives.

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¹https://www.mentalhealthamerica.net/sites/default/files/Commentary%20on%20Value%20Based%20Care%20final%20Nov%202017%20pdf%20%28002%29.pdf

² https://www.ncbi.nlm.nih.gov/pubmed/30305388

³ https://health.usnews.com/health-news/patient-advice/articles/2016-02-23/why-older-kids-need-well-child-checkups-too

⁴ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3551592/ ; https://www.sciencedaily.com/releases/2013/05/130524104642.htm