Addressing Emerging Needs Through the COVID-19 and Children With Medical Complexity ECHO.

The COVID-19 and Children with Medical Complexity (CMC) Extension for Community Healthcare Outcomes (ECHO) was developed as a "just in time" learning format to respond to the vast number of challenges faced by health care clinicians, public health professionals, and families/caregivers of CMC during the coronavirus disease 2019 (COVID-19) pandemic. A unique aspect of the ECHO was the meaningful integration of family leaders who participated as faculty, learners, case study presenters, and guest lecturers. Another distinguishing feature of this ECHO was its inclusion within a Collaborative Improvement and Innovation Network. A mixed methods analysis found that the COVID-19 and CMC ECHO was associated with significant gains in knowledge and confidence in caring for CMC and their families during the COVID-19 pandemic. This article provides an overview of the results of the COVID-19 and CMC ECHO and provides recommendations related to utilizing the ECHO model as a rapid response mechanism for systems improvement, clinical practice improvement, and education during a public health emergency.

Catalyzing Cross-Sector Collaboration: Lessons from a Virtual Pediatric Complex Care Coalition.

BACKGROUND: Children with complex health needs (CCHN) have intersecting medical, behavioral health, and social needs. Unfortunately, fragmentation across health and social services sectors often results in uncoordinated care for CCHN and their families. OBJECTIVE: The purpose of this article is to describe the creation of a statewide cross-sector partnership, the Children's Complex Care Coalition of North Carolina, to identify and act on opportunities for system-level improvements in the care of CCHN. METHODS: We applied a virtual community engagement approach to form an advisory committee of cross-sector collaborators; systematically identify priorities most important and urgent to collaborators for improving systems of care; and host a series of virtual convenings involving more than 90 attendees from across the state to operationalize collaborator-identified priorities into actionable next steps. LESSONS LEARNED: Key facilitators of success for the Children's Complex Care Coalition of North Carolina partnership were investing time in building trusting relationships, particularly with families of CCHN, and aligning goals and priorities with existing local and regional efforts. Challenges included incorporating traditionally under-represented perspectives, right-sizing virtual convening attendance and number of topics covered, and navigating technological difficulties in a virtual environment. CONCLUSIONS: Health systems can catalyze the formation of cross-sector coalitions and community partnerships to advance complex care. Virtual convenings with interactive activities and participatory structures can be an efficient medium to connect coalition members and elicit actionable recommendations for system-level improvements that address the needs of community members.

Research Agenda for Implementation of Principles of Care for Children and Youth With Special Health Care Needs.

OBJECTIVE: Children and youth with special health care needs (CYSHCN) have a range of medical, educational, and support service needs to achieve optimal health and wellness. Principles of care for CYSHCN have been well described, but the literature is lacking particularly on implementation and integration of care across different settings and systems. The objective of this manuscript is to define a research agenda for principles of care for CYSHCN. METHODS: Literature review examined principles of care for CYSHCN. Existing research gaps and priorities for principles of care were drawn from the literature review, a recently developed national research agenda for CYSHCN, and stakeholder consensus. RESULTS: Specific implementation areas of inquiry include family partner roles within and across systems; life course approach for CYSHCN; roles and training of interdisciplinary team members; and implementation, spread, and sustainability studies. Proposed methods include implementation science-based and comparative effectiveness research. A common set of metrics including health care utilization, clinical outcomes, and family and provider needs should be considered to evaluate implementation of principles of care. CONCLUSIONS: Implementation science and comparative effectiveness methods are needed to further understanding about how to adopt and spread principles of care for CYSHCN. The evolving demographics of CYSHCN add relevance and urgency for research findings.

Identifying Priorities to Improve the System of Care for Children With Complex Health Needs in North Carolina: Process and Outcomes of Systematic Stakeholder Engagement.

OBJECTIVE: Children with complex health needs (CCHN) have both medical (eg, chronic conditions) and health-related social needs (eg, potentially adverse social determinants of health) that require ongoing health care and support from multiple community service providers. National standards developed for populations defined by health needs (CYSHCN) provide a framework for stakeholders to plan system-level improvements in care delivery for CCHN, but improvement efforts should reflect the priorities of their families and providers. This article describes a process of prioritizing system-level efforts to improve the health and well-being of CCHN and families in North Carolina (NC), using systematic stakeholder engagement and modified Delphi expert ratings. METHODS: We surveyed stakeholders with experience caring for CCHN using an open-ended, 3-item instrument to identify opportunities to improve systems of care. Using directed qualitative content analysis, we synthesized responses into a master list of potential improvement topics. Using a modified Delphi approach, a 16-member advisory committee rated all topics for importance and urgency, on 9-point Likert scales over 2 rounds; then ratings for each topic were ranked (low, medium, high) to establish relative priority. RESULTS: Forty seven individuals from 31 counties around NC provided survey responses, yielding 59 improvement topics in 10 domains. Through the modified Delphi method process, 21 topics (36%) received the highest rankings, largely representing access to community- and home-based services, equity, and enhancement of the pediatric workforce. CONCLUSIONS: Priorities identified by stakeholders will inform advocacy, policy, and improvement efforts. Next steps for the coalition include developing improvement projects to implement stakeholder-recommended actions for the highest-priority topics.

Primary Care Quality Improvement Metrics and National Committee on Quality Assurance Medical Home Recognition for Children With Medical Complexity.

The Complex Care Center at Cincinnati Children's Hospital Medical Center developed and implemented a set of evidence-based clinical process measures of immunization delivery, preventive and chronic condition laboratory screening, and behavioral health medication surveillance for use in the primary care setting. METHODS: Improvement activities focused on 4 measures across 4 domains mandated by the National Committee on Quality Assurance for patient-centered medical home recognition. Interventions were implemented in phases from January 2017 to October 2018. The goal was the improvement in immunizations, preventive lead screening, vitamin D testing in chronic conditions, and behavioral health medication surveillance. Preventative lipid screening in the entire population and thyroid-stimulating hormone levels in patients with Down syndrome were also measured. RESULTS: The offering and the completion of an immunization bundle increased from a mean of 61.0% to a mean of 83.7% of patients. Eligible patients with documented lead surveillance increased from 61.2% to 96.5%. Patients with documented 25-hydroxy vitamin D levels increased from 72.2% to 87.8%. The percentage of patients metabolically monitored while taking an atypical antipsychotic continued at 92.0%. CONCLUSIONS: Using quality improvement education, data measurement/feedback, electronic medical record optimization/decision support, and care gap identification with planned care, the Complex Care Center demonstrated improved reliability in needed immunization delivery and laboratory screenings for a heterogeneous primary care population of children with medical complexity. As the numbers of children with medical complexity rise, so does the importance of reliable processes and relevant measures for quality in their unique care delivery systems.

Using Lean methodologies to streamline processing of requests for durable medical equipment and supplies for children with complex conditions.

BACKGROUND: An improvement team from the Complex Care Center at our large pediatric medical center participated in a 60-day initiative to use Lean methodologies to standardize their processes, eliminate waste and improve the timely and reliable provision of durable medical equipment and supplies. METHODS: The team used value stream mapping to identify processes needing improvement. Improvement activities addressed the initial processing of a request, provider signature on the form, returning the form to the sender, and uploading the completed documents to the electronic medical record. Data on lead time (time between receiving a request and sending the completed request to the Health Information Management department) and process time (amount of time the staff worked on the request) were collected via manual pre- and post-time studies. RESULTS: Following implementation of interventions, the median lead time for processing durable medical equipment and supply requests decreased from 50 days to 3 days (p < 0.0001). Median processing time decreased from 14min to 9min (p < 0.0001). The decrease in processing time realized annual cost savings of approximately $11,000. CONCLUSIONS: Collaborative leadership and multidisciplinary training in Lean methods allowed the CCC staff to incorporate common sense, standardize practices, and adapt their work environment to improve the timely and reliable provision of equipment and supplies that are essential for their patients. IMPLICATIONS: The application of Lean methodologies to processing requests for DME and supplies could also result in a natural spread to other paperwork and requests, thus avoiding delays and potential risk for clinical instability or deterioration.

Quality Improvement Strategies for Population Management of Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Children with medical complexity require the expertise of specialists and hospitals but may lack primary care to provide preventive, acute, and chronic care management. The Complex Care Center (CCC) at Cincinnati Children's Hospital Medical Center employed quality improvement methodologies in 3 initiatives to improve care for this fragile population. METHODS: Improvement activities focused on 3 main areas: population identification and stratification for care support, reliable delivery of preventive and chronic care, and planned care to identify and coordinate needed services. RESULTS: The percent of patients who attended a well-child care visit in the previous 13 months increased 91% and was sustained for the next year. The median monthly no-show rate remained unchanged. Within 10 months of implementing the interventions, >90% of CCC patients <7 years of age were receiving all recommended vaccines. Seventy-two percent of all CCC patients received their annual influenza vaccine. A sustained 98% to 100% of children with a complex chronic disease received previsit planning (PVP) for their well-child care and chronic condition management visits, whereas only 1 new patient did not receive PVP. CONCLUSIONS: Children with medical complexity require adaptations to typical primary care processes to support preventive health practices, chronic and acute care management, immunization, and collaborative care with their multiple specialists and support providers. We used quality improvement methodology to identify patients with the highest needs, reliably deliver appropriate preventive and chronic care, and implement PVP.

Applying the Chronic Care Model to Improve Care and Outcomes at a Pediatric Medical Center.

BACKGROUND: Cincinnati Children's Hospital Medical Center launched the Condition Outcomes Improvement Initiative in 2012 to help disease-based teams use the principles of improvement science to implement components of the Chronic Care Model and improve outpatient care delivery for populations of children with chronic and complex conditions. The goal was to improve outcomes by 20% from baseline. METHODS: Initiative activities included review of the evidence to choose and measure outcomes, development of condition-specific patient registries and tools for data collection, patient stratification, planning and coordinating care before and after visits, and self-management support. RESULTS: Eighteen condition teams, in sequenced cohorts, fully participated in the three-year initiative. As of October 1, 2015, data from 27,221 active patients with chronic conditions were entered into registries within the electronic health record and being used to inform quality improvement and population management. Overall, 13,601 of these children had an improved outcome. Seven of the teams had implemented their evidence-based interventions with ≥ 90% reliability, 83% of teams were regularly using an electronic template to plan care for a child's condition before an encounter, 89% had stratified their population by severity of medical/psychosocial needs, 56% were using registry care gap data for population management, and 72% were doing self-management assessments. Eleven teams achieved the numeric goal of 20% improvement in their chosen outcome. CONCLUSION: The results suggest that, by implementing quality improvement methods with multidisciplinary support, clinical teams can manage chronic condition populations and improve clinical, functional, and patient-reported outcomes. This work continues to be spread across the institution.

Medical Homes for Children With Special Health Care Needs: Primary Care or Subspecialty Service?

OBJECTIVE: To examine primary care pediatricians' (PCPs) beliefs about whether the family-centered medical home (FCMH) should be in primary or subspecialty care for children with different degrees of complexity; and to examine practice characteristics associated with these beliefs. METHODS: Data from the American Academy of Pediatrics Periodic Survey (PS 79) conducted in 2012 were analyzed. Outcomes were agreement/strong agreement that 1) primary care should be the FCMH locus for most children with special health care needs (CSHCN) and 2) subspecialty care is the best FCMH locus for children with rare or complex conditions. In multivariate models, we tested associations between outcomes and practice barriers (eg, work culture, time, cost) and facilitators (eg, having a care coordinator) to FCMH implementation. RESULTS: Among 572 PCPs, 65% agreed/strongly agreed primary care is the best FCMH setting for most CSHCN, and 43% agreed/strongly agreed subspecialty care is the best setting for children with complexity. Cost and time as barriers to FCMH implementation were oppositely associated with the belief that primary care was best for most CSHCN (cost: adjusted odds ratio [AOR] 2.31, 1.36-3.90; time: AOR 0.48, 0.29-0.81). Lack of skills to communicate and coordinate care was associated with the belief that specialty care was the best FCMH for children with complexity (AOR 1.99, 1.05-3.79). CONCLUSIONS: A substantial minority endorsed specialty care as the best FCMH locus for children with medical complexity. Several barriers were associated with believing primary care to be the best FCMH for most CSHCN. Addressing medical complexity in FCMH implementation may enhance perceived value by pediatricians.