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Cereal City Pediatric and Moazami Practice

Patient Engagement is the Key

Situation: The practice uses multiple ways to engage our community, families and patients. Recently the practice started using Facebook to get information out to both current and potential families in our area on important health information, seasonal concerns and news about the practice.

Strategy: The Website tag line- Welcome to Cereal City Pediatrics - we'll be there as they grow.... States from very first newborn checkup in the hospital to the unique health concerns of adolescents and every childhood illness in between, our caring providers have the expertise to help you safely navigate the sometimes confusing waters of children's health care. The website also has added many helpful pages: office hours, seasonal issues/concerns, is your Child Sick search, medication dosages, links to educational resources, scheduling, provider information, appointment guidance.  The practices have access 6 days a week in the summer and 7 in the winter with extended office hours 7:30am – 6:30pm M-F and on Saturday and Sunday 7:30am – 12 noon.  Patient hours are 8:00am – 6:00pm M-F with daily open slots for sick visits only from 4:30pm to 6:00pm M-F and on Saturday and Sunday 8 am to 11:30am to meet family needs.  Patient/family can schedule a get acquainted visit to the practice.  During their first visit as a patient they receive a Welcome to Cereal City practice folder which they are encouraged to bring to each visit. It contains:

· Information about office practice, providers, office hours, making appointments

· Calling the office after hours and weekends

· Immunization schedule

· Fever treatment

· Feeding

· Joining portal, how to create account

· Information practice needs


Their patient portal is used by families to access visit information, stores copies of forms, medical summery of all visits, or records needed for school or sports. It also provides frequently requested information like medication dosing. It also facilitates communication between provider, CM and family.

One week before a planned 9mo, 18mo or 2yr well visit families receive an age appropriate Ages and Stages questionnaire to fill out and bring back with them to the visit. They also can access SMART Healthy Behaviors Goal sheet with 5 questions help patient/families develop action plan based on their goals and needs. During their office visit there are given educational materials specific to visit type; this information is also forwarded to patient portal for families to have access later.  Parents are educated on immunization, choices and consequences.  AIM Toolkit from the Alliance for Immunizations in Michigan is used (  If the patient has an urgent care, emergency room or hospital visit a TOC call is done (based on criteria) to follow up. First question is “How are you and your child doing now?”

Triage nurses from the practice are on call at night and on weekends to answer questions and direct care. If family visits emergency room without calling the office first an opportunity is taken to educate the family to call office 1st. Diane Thomas, Office Manager, stated each contact with our families is an opportunity to support care from “first hello to last good bye”.  “Providing this level of care does not work unless everyone is on board. Everyone has a role and everyone touches the patient. Staff know what they do matters. Every visit is an opportunity to discuss and close care gaps.” “All staff have training and understands process and roles to identify and close gaps in care. “  Catching gaps in care starts with the front desk staff, they generate a gap in care report from the registry, and health plan. They place flags and tasks in the EMR to alert staff of what is needed. They also place this information on a pink encounter form, which follows the patient/family through the visit from the hello to check out.  They know why the patient and family are there.  During any visit the MA checks pink encounter form, MICR and EMR for HEDIS care gaps and closes according to protocols.

The provider reinforces care, referral and next follow-up visit. At checkout, the next visit is scheduled from the pink encounter form. Education and materials are provided throughout the visit and attached to the portal. Office scanner makes sure referrals and reports get into chart. Amy Goff, Care Manager, focuses on both moderate and complex care management. She has an introduction letter for patients who may benefit from care management along with  follow up contact letters for patients. She looks for every opportunity to help staff to understand care for each CM patient and be part of cheering them on when they are meeting their goals.

Asthma patients receive a Red Folder with educational fliers and symptom log to help document symptom, track treatment and impact. There is consistent ongoing education and teach back patient demonstration on use of inhaler and spacers at each visit.

Dee Dailey, Practice Coach, is viewed as part of the team keeping them aware of the data and assisting with opportunities for improvement. She presents at quarterly staff meetings the Quality Data Board with updated reports, raw data and specific cases for gaps not met. She helps staff see the impact of improvements and that what they do matters.


For more information on the great work Cereal City has been doing please contact Wendy Hanson @