A Tertiary Care-based Complex Care Program: Improving Care for Children With Medical Complexity.

OBJECTIVE: Children with medical complexity (CMC) have significant health care costs, but they also experience substantial unmet health care needs, hospitalizations, and medical errors. Their parents often report psychosocial stressors and poor care satisfaction. Complex care programs can improve the care for CMC. At our tertiary care institution, we developed a consultative complex care program to improve the quality and cost of care for CMC and to improve the experience of care for patients and families. METHODS: To address the needs of CMC at our institution, we developed the Compass Care Program, a consultative complex care program across inpatient and outpatient settings. Utilization data [hospital admissions per patient month; length of stay per admission; hospital days per patient month; emergency department (ED) visits per patient month; and institutional charges per patient month] and caregiver satisfaction data (obtained via paper survey at outpatient visits) were tracked over the period of participation in the program and compared preenrollment and postenrollment for program participants. RESULTS: Participants had significant decreases in hospital admissions per patient month, length of stay per admission, hospital days per patient month, and charges per patient month following enrollment (P<0.01) without a tandem increase in readmissions within 7 days of discharge. There was no statistically significant difference in ED visits. Caregiver satisfaction scores improved in all domains. CONCLUSION: Participation in a consultative complex care program can improve utilization patterns and cost of care for CMC, as well as experience of care for patients and families.

Pediatric Population Management Classification for Children with Medical Complexity.

Improving the overall care of children with medical complexity (CMC) is often beset by challenges in proactively identifying the population most in need of clinical management and quality improvement. The objective of the current study was to create a system to better capture longitudinal risk for sustained and elevated utilization across time using real-time electronic health record (EHR) data. A new Pediatric Population Management Classification (PPMC), drawn from visit diagnoses and continuity problem lists within the EHR of a tristate health system, was compared with an existing complex chronic conditions (CCC) system for agreement (with weighted κ) on identifying CCMC, as well as persistence of elevated charges and utilization from 2016 to 2019. Agreement of assignment PPMC was lower among primary care provider (PCP) populations than among other children traversing the health system for specialty or hospital services only (weighted κ 62% for PCP vs. 82% for non-PCP). The PPMC classification scheme, displaying greater precision in identifying CMC with persistently high utilization and charges for those who receive primary care within a large integrated health network, may offer a more pragmatic approach to selecting children with CMC for longitudinal care management.

Medication Rounds: A Tool to Promote Medication Safety for Children with Medical Complexity.

Children with medical complexity (CMC) often have lengthy medication lists and are at risk of experiencing suboptimal medication management. This tool tutorial describes a novel and pragmatic strategy for the development and implementation of medication rounds, a model that promotes medication safety for hospitalized CMC. An interprofessional group designed and implemented a pharmacy-led medication rounding care model, in which clinicians and pharmacists partner weekly to conduct reviews of all patient medications on a general pediatrics CMC team using a comprehensive checklist. This approach fosters medication safety for hospitalized CMC and could be adapted to other complex inpatient populations.

The Goldilocks problem: Healthcare delivery models for children with medical complexity.

Health systems have increasingly adapted elements of the medical home model in designing complex care programs for children with medical complexity (CMC). In recent years, several key complex care program designs have emerged. These programs have been shown to be effective in improving the quality and cost of care for CMC. In designing and implementing a complex care model, there are many variables a health system must consider to ensure program viability. To address CMC across the continuum of care, tertiary care systems should implement a portfolio of complex care models to accommodate the population's diverse needs. Further study is needed to establish 'gold standards' for complex care delivery models, but a major factor affecting program innovation is reimbursement, as the fee for service model does not adequately support the enhanced services required to ensure high value, high quality care for CMC. It is thus critical that stakeholders from health systems and payers align to engage in innovation in complex care delivery design and implementation. Without this partnership, advances in care delivery for CMC will be limited.

Implementation of a Follow-Up System for Pediatric Sepsis Survivors in a Large Academic Pediatric Intensive Care Unit.

Background: Survivors of pediatric sepsis often develop new morbidities and deterioration in quality of life after sepsis, leading to a need for improved follow-up for children who survive sepsis. Objective: To implement a follow-up system for pediatric sepsis survivors in a pediatric health system. Methods: We performed a retrospective case series of patients treated for sepsis from October 2018 through October 2019 in a pediatric intensive care unit in a quaternary children's hospital, and describe implementation of a follow-up system for sepsis survivors. Program planning started in 2017 with multidisciplinary meetings including physical, occupational, and speech therapists, teachers, neuropsychologists, and coordinators from other survivorship programs (neonatology, stroke, and oncology). In 2018, a workshop was held to consult with local and national experts. The Pediatric Sepsis Survivorship Program launched in October 2018 led by a nurse coordinator who met with families to educate about sepsis and offer post-discharge follow-up. Patients with high pre-existing medical complexity or established subspecialty care were referred for follow-up through existing care coordination or subspecialty services plus guidance to monitor for post-sepsis morbidity. For patients with low-moderate medical complexity, the nurse coordinator administered a telephone-based health-assessment 2-3 months after discharge to screen for new physical or psychosocial morbidity. Patients flagged with concerns were referred to their primary physician and/or to expedited neuropsychological evaluation to utilize existing medical services. Results: Of 80 sepsis patients, 10 died, 20 were referred to care coordination by the program, and 13 had subspecialty follow-up. Five patients were followed in different health systems, four were adults not appropriate for existing follow-up programs, four remained hospitalized, and four were missed due to short stay or unavailable caregivers. The remaining 20 patients were scheduled for follow-up with the Pediatric Sepsis Program. Nine patients completed the telephone assessment. Four patients were receiving new physical or occupational therapy, and one patient was referred for neuropsychology evaluation due to new difficulties with attention, behavior, and completion of school tasks. Conclusions: Implementation of an efficient, low-cost pediatric sepsis survivorship program was successful by utilizing existing systems of care, when available, and filling a follow-up gap in screening for select patients.

Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children.

Importance: As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources. Objective: To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days. Design, Setting, and Participants: This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019. Exposures: Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers. Main Outcomes and Measures: Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017). Results: Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid. Conclusions and Relevance: In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.

The Pediatric Aerodigestive Center as a Tertiary Care-Based Medical Home: A Proposed Model.

Children with special healthcare needs have been identified nationally as a population whose health care is associated with unmet needs; increased morbidity; fragmentation of care and medical errors; caregiver dissatisfaction; and disproportionately high costs. A subset of these children are medically fragile, with medical complexity that requires a reliance on tertiary care-based services-including subspecialty appointments, surgical procedures, and care coordination resources. For medically complex patients affected by upper and lower respiratory tract and gastrointestinal disorders, multidisciplinary aerodigestive centers have emerged at tertiary care centers across the United States to facilitate coordinated, high-quality, and high value care. We propose that the aerodigestive center is an effective vehicle for a tertiary care-based medical home. Within this model, the integration of a general pediatrician will help promote holistic, patient-centered care, and the general pediatrician can serve to both support and provide continuity with the primary care medical home.

Developing the Capacity for Rapid-Cycle Improvement at a Large Freestanding Children's Hospital.

BACKGROUND: To develop the capacity for rapid-cycle improvement at the unit level, a large freestanding children's hospital designated 2 inpatient units with normal patient loads and workforce as pilot "Innovation Units" where frontline staff was trained to lead rigorous improvement portfolios. METHODS: Frontline staff received improvement training, and interdisciplinary teams brainstormed ideas for tests of change. Ideas were prioritized using an impact-effort evaluation and an assessment of how they aligned with high-level goals. A template for each test summarized the following: the opportunity for improvement, the test being conducted, dates for the tests, driver diagrams, metrics to measure effects, baseline data, results, findings, and next steps. Successful interventions were implemented and disseminated to other units. RESULTS: Multidisciplinary staff generated 150 improvement ideas and Innovation Units collectively ran >40 plan-do-study-act cycles. Of the 10 distinct improvement projects, elements of all 10 were deemed "successful" and fully implemented on the unit, and elements from 8 were spread to other units. More than 3 years later, elements of all of the successful improvements are still in practice in some form on the units, and each unit has tested >20 additional improvement ideas, using multiple plan-do-study-act cycles to refine them. CONCLUSIONS: The Innovation Unit model successfully engaged frontline staff in improvement work and established a sustainable system and framework for managing rigorous improvement portfolios at the unit level. Other hospitals and health care delivery settings may find our quality improvement approach helpful, especially because it is rooted in the microsystem of care delivery.