Optimizing the multidisciplinary team to enhance care coordination across the continuum for children with medical complexity.

The number of individual patients needing the support of complex care coordination to help manage chronic illness and functional disability and to negotiate systemic barriers to care continues to grow. Children with medical complexity (CMC) require a multidisciplinary team approach to address their complex health care needs.  CMC may have multiple health conditions affecting numerous body systems, increased use of the health care system, and technology dependence.  A cohesive team approach to care for CMC is necessary to ensure that there are clearly defined roles for each member of the care team and the individualized plan of care is implemented with the unique needs of the patient and family at the center of the care. This article will outline the roles of the essential providers that support these children.

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.