101
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Meehan E, D’Aprano AL, Gibb SM, Mountford NJ, Williams K, Harvey AR, Connell TG, Cohen E. Comprehensive care programmes for children with medical complexity. Hippokratia 2019. [DOI: 10.1002/14651858.cd013329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Elaine Meehan
- Murdoch Children's Research Institute; Neurodisability and Rehabilitation; 50 Flemington Road Melbourne Victoria Australia 3052
| | - Anita L D’Aprano
- The Royal Children's Hospital; General Medicine; Melbourne Australia
| | - Susan M Gibb
- The Royal Children's Hospital; Neurodevelopment and Disability; Melbourne Australia
| | - Nicki J Mountford
- The Royal Children's Hospital; Complex Care Hub; Melbourne Australia
| | - Katrina Williams
- The University of Melbourne; Department of Paediatrics; Melbourne Australia
| | - Adrienne R Harvey
- Murdoch Children's Research Institute; Neurodisability and Rehabilitation; 50 Flemington Road Melbourne Victoria Australia 3052
| | - Tom G Connell
- The Royal Children's Hospital; General Medicine; Melbourne Australia
| | - Eyal Cohen
- University of Toronto; Pediatrics and Health Policy, Management & Evaluation; The Hospital for Sick Children 555 University Avenue Toronto ON Canada M5G 1X8
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102
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Bjur KA, Wi CI, Ryu E, Crow SS, King KS, Juhn YJ. Epidemiology of Children With Multiple Complex Chronic Conditions in a Mixed Urban-Rural US Community. Hosp Pediatr 2019; 9:281-290. [PMID: 30923070 PMCID: PMC6434974 DOI: 10.1542/hpeds.2018-0091] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Children with multiple complex chronic conditions (MCCs) represent a small fraction of our communities but a disproportionate amount of health care cost and mortality. Because the temporal trends of children with MCCs within a geographically well-defined US pediatric population has not been previously assessed, health care planning and policy for this vulnerable population is limited. METHODS In this population-based, repeated cross-sectional study, we identified and enrolled all eligible children residing in Olmsted County, Minnesota, through the Rochester Epidemiology Project, a medical record linkage system of Olmsted County residents. The pediatric complex chronic conditions classification system version 2 was used to identify children with MCCs. Five-year period prevalence and incidence rates were calculated during the study period (1999-2014) and characterized by age, sex, ethnicity, and socioeconomic status (SES) by using the housing-based index of socioeconomic status, a validated individual housing-based SES index. Age-, sex-, and ethnicity-adjusted prevalence and incidence rates were calculated, adjusting to the 2010 US total pediatric population. RESULTS Five-year prevalence and incidence rates of children with MCCs in Olmsted County increased from 1200 to 1938 per 100 000 persons and from 256 to 335 per 100 000 person-years, respectively, during the study period. MCCs tend to be slightly more prevalent among children with a lower SES and with a racial minority background. CONCLUSIONS Both 5-year prevalence and incidence rates of children with MCCs have significantly increased over time, and health disparities are present among these children. The clinical and financial outcomes of children with MCCs need to be assessed for formulating suitable health care planning given limited resources.
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103
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Medication Reconciliation Across Care Transitions in the Pediatric Medical Home. Jt Comm J Qual Patient Saf 2019; 45:536-542. [PMID: 30898508 DOI: 10.1016/j.jcjq.2019.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 01/28/2019] [Accepted: 01/29/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize medication discrepancies for patients with chronic illnesses seen at outside facilities. METHODS This was a retrospective evaluation of a medication reconciliation across care transitions (MRAT) program developed and piloted for one year in an academic pediatric primary care medical home. The MRAT involved chart review and contacting caregivers upon receiving external specialist notes or hospital discharge summaries. Data obtained from the program were used to determine the frequency and types of medication discrepancies for children with complex and noncomplex chronic conditions. RESULTS MRATs for 124 encounters were evaluated, 74.0% in response to specialist appointments. Chart review revealed a mean of 3.64 discrepancies per patient, and telephone calls revealed 1.39 additional discrepancies per patient. The number of medication discrepancies from both chart review and telephone calls between complex and noncomplex patients was statistically significant, with a mean of 5.63 vs. 3.77 per patient (p = 0.005). Therapy delays occurred in 16.1% of patients due to insurance rejections, family not starting a new medicine, or confusion about the medication change. Mean time required for reconciliation was 24 minutes. In addition to medication reconciliation, 107 interventions completed during MRATs included patient education, adjusting drug therapy, coordinating care between providers, recommending laboratory monitoring, and facilitating patient appointments. CONCLUSION Children with chronic illness often experience medication changes and delays in therapy when seen in the hospital or by specialists. Timely identification of these changes improves communication and offers the opportunity to identify and prevent problems with medication therapy.
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104
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Kuo DZ. The Medical Home for Children with Medical Complexity: Back to Basics. J Pediatr 2019; 206:8-9. [PMID: 30553538 DOI: 10.1016/j.jpeds.2018.11.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 11/28/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Dennis Z Kuo
- Department of Pediatrics University at Buffalo Buffalo, New York.
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105
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Ming DY, Jackson GL, Sperling J, Gray M, Wyman Roth N, Spears T, Parente V, Bosworth H. Mobile Complex Care Plans to Enhance Parental Engagement for Children With Medical Complexity. Clin Pediatr (Phila) 2019; 58:34-41. [PMID: 30295060 DOI: 10.1177/0009922818805241] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Care plans can reduce care fragmentation for children with medical complexity (CMC); however, implementation is challenging. Mobile health innovations could improve implementation. This mixed methods study's objectives were to (1) evaluate feasibility of mobile complex care plans (MCCPs) for CMC enrolled in a complex care program and (2) study MCCPs' impact on parent engagement, parent experience, and care coordination. MCCPs were individualized, updated quarterly, integrated within the electronic health record, and visible on parents' mobile devices via an online portal. In 1 year (September 1, 2016, to August 31, 2017), 94% of eligible patients (n = 47) received 162 MCCPs. Seventy-four percent of parents (n = 35) reviewed MCCPs online. Forty-six percent of these parents (n = 16) sent a follow-up message, and the care team responded within 8 hours (median time = 7.2 hours). In interviews, parents identified MCCPs as an important reference and communication tool. MCCPs for CMC in a complex care program were feasible, facilitated parental engagement, and delivered timely communication.
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Affiliation(s)
- David Y Ming
- 1 Department of Pediatrics, Division of Pediatric Hospital Medicine, Duke University School of Medicine, Durham, NC, USA.,2 Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - George L Jackson
- 2 Department of Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA.,3 Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,4 Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Jessica Sperling
- 5 Social Science Research Institute (SSRI), Education and Human Development Incubator (EHDi), Duke University, Durham, NC, USA
| | - Megan Gray
- 5 Social Science Research Institute (SSRI), Education and Human Development Incubator (EHDi), Duke University, Durham, NC, USA
| | - Noelle Wyman Roth
- 5 Social Science Research Institute (SSRI), Education and Human Development Incubator (EHDi), Duke University, Durham, NC, USA
| | - Tracy Spears
- 6 Department of Pediatrics, Division of Quantitative Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Victoria Parente
- 1 Department of Pediatrics, Division of Pediatric Hospital Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Hayden Bosworth
- 3 Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA.,4 Center for Health Services Research in Primary Care, Durham Veterans Affairs Health Care System, Durham, NC, USA.,7 Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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106
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Coller RJ, Ehlenbach ML. Making Time to Coordinate Care for Children With Medical Complexity. Pediatrics 2019; 143:peds.2018-2958. [PMID: 30584058 DOI: 10.1542/peds.2018-2958] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mary L Ehlenbach
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
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107
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Adams S, Nicholas D, Mahant S, Weiser N, Kanani R, Boydell K, Cohen E. Care maps and care plans for children with medical complexity. Child Care Health Dev 2019; 45:104-110. [PMID: 30462842 DOI: 10.1111/cch.12632] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 08/15/2018] [Accepted: 11/15/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The support of families in the care of children with medical complexity (CMC) requires the integration of health care providers' (HCPs') medical knowledge and family experience. Care plans largely represent HCP information, and care maps demonstrate the family experience. Understanding the intersection between a care plan and a care map is critical, as it may provide solutions to the widely recognized tension between HCP-directed care and patient- and family-centered care (PFCC). METHOD This study used qualitative methods to explore the experience and usefulness of care maps. Parents of CMC who already had a care plan, created care maps (n = 15). Subsequent interviews with parents (n = 15) and HCPs (n = 30) of CMC regarding both care maps and care plans were conducted and analyzed using thematic analysis. RESULTS Data analysis exploring the relationship and utility of care plans and care maps revealed six primary themes related to using care plans and care maps that were grouped into two primary categories: (a) utility of care plans and maps; and (b) intersection of care plans and care maps. DISCUSSION Care plans and care maps were identified as valuable complementary documents. Their integration offers context about family experience and respects the parents' experiential wisdom in a standard patient care document, thus promoting improved understanding and integration of the family experience into care decision making.
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Affiliation(s)
- Sherri Adams
- Division of Paediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - David Nicholas
- Faculty of Social Work, University of Calgary (Edmonton Division), Edmonton, Alberta, Canada
| | - Sanjay Mahant
- Division of Paediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Natalie Weiser
- Division of Paediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronik Kanani
- Maternal, Newborn and Paediatric Care Program, North York General Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Katherine Boydell
- Black Dog Institute, University of New South Wales, Randwick, New South Wales, Australia.,Child and Youth Mental Health Research Unit, The Hospital for Sick Children, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, Universality of Toronto, Toronto, Ontario, Canada
| | - Eyal Cohen
- Division of Paediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada.,Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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108
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Nackers A, Ehlenbach M, Kelly MM, Werner N, Warner G, Coller RJ. Encounters From Device Complications Among Children With Medical Complexity. Hosp Pediatr 2018; 9:6-15. [PMID: 30530805 DOI: 10.1542/hpeds.2018-0103] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Children with medical complexity (CMC) are commonly assisted by medical devices to support essential body functions, although complications may lead to preventable emergency department (ED) and hospital use. Our objective was to identify predictors of device-complicated ED visits and hospitalizations. METHODS This single-center retrospective cohort study included patients referred to a Pediatric Complex Care Program between April 1, 2014, and April 30, 2016, assisted by at least 1 medical device. Hospitalizations and ED visits in the year before enrollment were rated for likelihood for being due to device complications. Interrater reliability among 3 independent reviewers was assessed. Bivariate followed by multivariate logistic regression clustered by patient helped us identify associations between demographic, clinical, and device characteristics associated with device-complicated ED or hospital encounters. RESULTS Interrater reliability was high (κ = 0.92). Among 98 CMC, device-complicated encounters represented 17% of 258 hospitalizations and 31% of 228 ED visits. Complications of 3 devices (central venous catheters, enteral tubes, and tracheostomy tubes) accounted for 13% of overall hospitalizations and 28% of overall ED visits. Central venous catheter presence (adjusted odds ratio [aOR] 3.2 [95% confidence interval (CI) 1.1-9.5]) was associated with device-complicated ED visits. Gastrojejunostomy/jejunostomy tube presence (aOR 3.3 [95% CI 1.5-7.5]) or tracheostomies with (aOR 8.1 [95% CI 2.3-28.5]) or without (aOR 4.5 [95% CI 1.7-7.5]) ventilator use was associated with device-complicated hospitalizations. Clinical variables were poor predictors of device-complicated encounters. CONCLUSIONS Device-complicated ED visits and hospitalizations comprised a substantial proportion of total hospital and ED use. Developing interventions to prevent device complications may be a promising strategy to reduce overall CMC use.
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Affiliation(s)
- Allison Nackers
- Department of Pediatrics, School of Medicine and Public Health
| | - Mary Ehlenbach
- Department of Pediatrics, School of Medicine and Public Health
| | - Michelle M Kelly
- Department of Pediatrics, School of Medicine and Public Health.,Center for Quality and Productivity Improvement, and
| | - Nicole Werner
- Center for Quality and Productivity Improvement, and.,Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Gemma Warner
- Department of Pediatrics, School of Medicine and Public Health
| | - Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health,
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109
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Nkoy FL, Hofmann MG, Stone BL, Poll J, Clark L, Fassl BA, Murphy NA. Information needs for designing a home monitoring system for children with medical complexity. Int J Med Inform 2018; 122:7-12. [PMID: 30623786 DOI: 10.1016/j.ijmedinf.2018.11.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 10/08/2018] [Accepted: 11/25/2018] [Indexed: 10/27/2022]
Abstract
Background Children with medical complexity (CMC) are a growing population of medically fragile children with unique healthcare needs, who have recurrent emergency department (ED) and hospital admissions due to frequent acute escalations of their chronic conditions. Mobile health (mHealth) tools have been suggested to support CMC home monitoring and prevent admissions. No mHealth tool has ever been developed for CMC and challenges exist. Objective To: 1) assess information needs for operationalizing CMC home monitoring, and 2) determine technology design functionalities needed for building a mHealth application for CMC. Methods Qualitative descriptive study conducted at a tertiary care children's hospital with a purposive sample of English-speaking caregivers of CMC. We conducted 3 focus group sessions, using semi-structured, open-ended questions. We assessed caregiver's perceptions of early symptoms that commonly precede acute escalations of their child conditions, and explored caregiver's preferences on the design functionalities of a novel mHealth tool to support home monitoring of CMC. We used content analysis to assess caregivers' experience concerning CMC symptoms, their responses, effects on caregivers, and functionalities of a home monitoring tool. Results Overall, 13 caregivers of CMC (ages 18 months to 19 years, mean = 9 years) participated. Caregivers identified key symptoms in their children that commonly presented 1-3 days prior to an ED visit or hospitalization, including low oxygen saturations, fevers, rapid heart rates, seizures, agitation, feeding intolerance, pain, and a general feeling of uneasiness about their child's condition. They believed a home monitoring system for tracking these symptoms would be beneficial, providing a way to identify early changes in their child's health that could prompt a timely and appropriate intervention. Caregivers also reported their own symptoms and stress related to caregiving activities, but opposed monitoring them. They suggested an mHealth tool for CMC to include the following functionalities: 1) symptom tracking, targeting commonly reported drivers (symptoms) of ED/hospital admissions; 2) user friendly (ease of data entry), using voice, radio buttons, and drop down menus; 3) a free-text field for reporting child's other symptoms and interventions attempted at home; 4) ability to directly access a health care provider (HCP) via text/email messaging, and to allow real-time sharing of child data to facilitate care, and 5) option to upload and post a photo or video of the child to allow a visual recall by the HCP. Conclusions Caregivers deemed a mHealth tool beneficial and offered a set of key functionalities to meet information needs for monitoring CMC's symptoms. Our future efforts will consist of creating a prototype of the mHealth tool and testing it for usability among CMC caregivers.
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Affiliation(s)
- Flory L Nkoy
- University of Utah, Pediatric Department, SLC, Utah, United States.
| | | | - Bryan L Stone
- University of Utah, Pediatric Department, SLC, Utah, United States
| | - Justin Poll
- Intermountain Healthcare, SLC, Utah, United States
| | - Lauren Clark
- University of Utah, Pediatric Department, SLC, Utah, United States
| | - Bernhard A Fassl
- University of Utah, Pediatric Department, SLC, Utah, United States
| | - Nancy A Murphy
- University of Utah, Pediatric Department, SLC, Utah, United States
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110
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White PH, Cooley WC, Boudreau ADA, Cyr M, Davis BE, Dreyfus DE, Forlenza E, Friedland A, Greenlee C, Mann M, McManus M, Meleis AI, Pickler L. Supporting the Health Care Transition From Adolescence to Adulthood in the Medical Home. Pediatrics 2018; 142:peds.2018-2587. [PMID: 30348754 DOI: 10.1542/peds.2018-2587] [Citation(s) in RCA: 415] [Impact Index Per Article: 69.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Risk and vulnerability encompass many dimensions of the transition from adolescence to adulthood. Transition from pediatric, parent-supervised health care to more independent, patient-centered adult health care is no exception. The tenets and algorithm of the original 2011 clinical report, "Supporting the Health Care Transition from Adolescence to Adulthood in the Medical Home," are unchanged. This updated clinical report provides more practice-based quality improvement guidance on key elements of transition planning, transfer, and integration into adult care for all youth and young adults. It also includes new and updated sections on definition and guiding principles, the status of health care transition preparation among youth, barriers, outcome evidence, recommended health care transition processes and implementation strategies using quality improvement methods, special populations, education and training in pediatric onset conditions, and payment options. The clinical report also includes new recommendations pertaining to infrastructure, education and training, payment, and research.
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Affiliation(s)
- Patience H. White
- Got Transition/The National Alliance to Advance Adolescent Health and Department of Medicine and Pediatrics, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia; and
| | - W. Carl Cooley
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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111
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Trout CJ, Case LE, Clemens PR, McArthur A, Noritz G, Ritzo M, Wagner KR, Vroom E, Kennedy A. A Transition Toolkit for Duchenne Muscular Dystrophy. Pediatrics 2018; 142:S110-S117. [PMID: 30275255 DOI: 10.1542/peds.2018-0333m] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2018] [Indexed: 11/24/2022] Open
Abstract
The care of individuals with Duchenne muscular dystrophy (DMD) now extends into adulthood. Childhood to adulthood transition planning is an important aspect of care, affecting health outcomes as well as other important aspects of adult life. In this article, we address transition planning as it relates to DMD health care, education, steps toward vocations, personal care, accessing the home and community, and the importance of relationships with others. Because of the complex, disabling, and progressive nature of DMD, coordinated, well-timed planning is critical to ensure that all components of transition are accomplished. In this article, we introduce the DMD Transition Toolkit. The toolkit is designed to help assess readiness for transition, track progress toward transition goals, and provide a template for documenting key elements of medical care, medical equipment, and services. The transition readiness assessment for young adults with DMD is used to gauge readiness for adult health care and living practices. Consistent with the 2018 DMD Care Considerations, the transition checklist for young adults with DMD is a comprehensive list to be considered, discussed, and planned for during transition. The medical summary for young adults with DMD can be used by a provider or individuals with DMD to communicate details of their health plan, provider contacts, and medical equipment needs. It can be used in transition handoffs, when adding new providers, or when informing new nursing agencies or personal care attendants. It could also be useful in urgent care settings by providing baseline information about the individual with DMD.
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Affiliation(s)
- Christina J Trout
- Division of Child Neurology, Department of Pediatrics, University of Iowa, Iowa City, Iowa;
| | - Laura E Case
- Doctor of Physical Therapy Division, Department of Orthopedics, School of Medicine, Duke University, Durham, North Carolina
| | - Paula R Clemens
- Department of Neurology, University of Pittsburgh School of Medicine and Neurology Division, Department of Veterans Affairs Medical Center, Pittsburgh, Pennsylvania
| | - Alexandra McArthur
- North Carolina Council on Developmental Disabilities, Raleigh, North Carolina
| | - Garey Noritz
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio.,Department of Pediatrics, The Ohio State University, Columbus, Ohio
| | - Marie Ritzo
- Department of Family Services/Clinical Social Work, Children's National Medical Center, Washington, District of Columbia
| | - Kathryn R Wagner
- Kennedy Krieger Institute, Baltimore, Maryland.,School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Elizabeth Vroom
- Duchenne Parent Project Netherlands, Amsterdam, Netherlands; and
| | - Annie Kennedy
- Parent Project Muscular Dystrophy, Hackensack, New Jersey
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112
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Readiness for an Increase in Congenital Zika Virus Infections in the United States: Geographic Distance to Pediatric Subspecialist Care. Disaster Med Public Health Prep 2018; 13:476-486. [PMID: 30139407 DOI: 10.1017/dmp.2018.77] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The study's purpose was to investigate readiness for an increase in the congenital Zika infection (CZI) by describing the distribution of pediatric subspecialists needed for the care of children with CZI. METHODS We applied county-level subspecialist counts to US maps, overlaying the geocoded locations of children's hospitals to assess the correlation of hospital and subspecialist locations. We calculated travel distance from census tract centroids to the nearest in-state children's hospital by state (with/without > 100 reported adult Zika virus cases) and by regions corresponding to the likely local Zika virus transmission area and to the full range of the mosquito vector. Travel distance percentiles reflect the population of children 100 miles. CONCLUSION The travel distance to pediatric subspecialty care varies widely by state and is likely to be an access barrier in some areas, particularly states bordering the Gulf of Mexico, which may have increasing numbers of CZI cases. (Disaster Med Public Health Preparedness. 2019;13:476-486).
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113
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Donley T, King DM, Nyathi N, Okafor A, Mbizo J. Socioeconomic Status, Family Functioning and Delayed Care Among Children With Special Needs. SOCIAL WORK IN PUBLIC HEALTH 2018; 33:366-381. [PMID: 30124396 DOI: 10.1080/19371918.2018.1504703] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Parents of children with special healthcare needs (CSHCN) face tremendous stress in caring for their children. Families of CSHCN face increased barriers to health services as evidence also reflects the influence of socioeconomic factors on access. This study investigates the impact of socioeconomic factors and family functioning on delayed care. Descriptive, bivariate, and adjusted multivariate logistic regression were performed using sampling weights. findings suggest that family dynamics are more impactful on delayed care than socioeconomic predictors. Promoting family-centered care that incorporates social support for families to reduce barriers is essential for improved quality of life and health outcomes.
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Affiliation(s)
- Tiffany Donley
- a Department of Public Health, University of West Florida , Pensacola , Florida , USA
| | - Dione Moultrie King
- b Department of Social Work, University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Nhlanganiso Nyathi
- c Department of Education and Social Care, Anglia Ruskin University , Peterborough
| | - Anthony Okafor
- a Department of Public Health, University of West Florida , Pensacola , Florida , USA
| | - Justice Mbizo
- a Department of Public Health, University of West Florida , Pensacola , Florida , USA
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114
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Simon TD, Haaland W, Hawley K, Lambka K, Mangione-Smith R. Development and Validation of the Pediatric Medical Complexity Algorithm (PMCA) Version 3.0. Acad Pediatr 2018; 18:577-580. [PMID: 29496546 PMCID: PMC6035108 DOI: 10.1016/j.acap.2018.02.010] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/10/2018] [Accepted: 02/17/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To modify the Pediatric Medical Complexity Algorithm (PMCA) to include both International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) codes for classifying children with chronic disease (CD) by level of medical complexity and to assess the sensitivity and specificity of the new PMCA version 3.0 for correctly identifying level of medical complexity. METHODS To create version 3.0, PMCA version 2.0 was modified to include ICD-10-CM codes. We applied PMCA version 3.0 to Seattle Children's Hospital data for children with ≥1 emergency department (ED), day surgery, and/or inpatient encounter from January 1, 2016, to June 30, 2017. Starting with the encounter date, up to 3 years of retrospective discharge data were used to classify children as having complex chronic disease (C-CD), noncomplex chronic disease (NC-CD), and no CD. We then selected a random sample of 300 children (100 per CD group). Blinded medical record review was conducted to ascertain the levels of medical complexity for these 300 children. The sensitivity and specificity of PMCA version 3.0 was assessed. RESULTS PMCA version 3.0 identified children with C-CD with 86% sensitivity and 86% specificity, children with NC-CD with 65% sensitivity and 84% specificity, and children without CD with 77% sensitivity and 93% specificity. CONCLUSIONS PMCA version 3.0 is an updated publicly available algorithm that identifies children with C-CD, who have accessed tertiary hospital emergency department, day surgery, or inpatient care, with very good sensitivity and specificity when applied to hospital discharge data and with performance to earlier versions of PMCA.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash; Seattle Children's Research Institute, Seattle, Wash.
| | - Wren Haaland
- Seattle Children's Research Institute, Seattle, Wash
| | | | - Karen Lambka
- Seattle Children's Research Institute, Seattle, Wash
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Wash; Seattle Children's Research Institute, Seattle, Wash
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115
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Smith EM, Gowran RJ, Mannan H, Donnelly B, Alvarez L, Bell D, Contepomi S, Ennion Wegner L, Hoogerwerf EJ, Howe T, Jan YK, Kagwiza J, Layton N, Ledgerd R, MacLachlan M, Oggero G, Pettersson C, Pousada T, Scheffler E, Wu S. Enabling appropriate personnel skill-mix for progressive realization of equitable access to assistive technology. Disabil Rehabil Assist Technol 2018; 13:445-453. [PMID: 29772939 DOI: 10.1080/17483107.2018.1470683] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND METHODS This paper reviews the current capacity of personnel in enabling access to assistive technology (AT) as well as the systems and processes within which they work, and was reviewed, discussed, and refined during and following the Global Research, Innovation, and Education in Assistive Technology (GREAT) Summit. FINDINGS Key concepts addressed include a person-centred team approach; sustainability indicators to monitor, measure, and respond to needs for service design and delivery; education, research, and training for competent practice, using the six rehab-workforce challenges framework; and credentialing frameworks. We propose development of a competence framework and associated education and training programs, and development and implementation of a certification framework for AT personnel. CONCLUSIONS There is a resolve to address the challenges faced by People globally to access assistive technology. Context specific needs assessment is required to understand the AT Personnel landscape, to shape and strengthen credentialing frameworks through competencies and certification, acknowledging both general and specific skill mix requirements. Implications for Rehabilitation Personnel in assistive technology (AT) provision should be trained using a person-centred team approach, which emphasizes appropriate skill-mix to address multiple needs within the community. Sustainability indicators should be used which allow personnel to monitor, measure and respond to needs for service design and delivery. A competence framework with associated education and training program, coupled with the development and implementation of a certification framework for AT personnel needs, will promote quality in AT personnel training globally.
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Affiliation(s)
- Emma M Smith
- a Rehabilitation Sciences, GF Strong Rehabilitation Research Program, University of British Columbia , Vancouver , Canada
| | - Rosemary Joan Gowran
- b School of Allied Health, University of Limerick , Limerick , Ireland.,c University of Sunshine Coast , Sunshine Coast , Australia
| | - Hasheem Mannan
- d School of Nursing, Midwifery & Health Systems Health Sciences Centre, University College Dublin , Dublin , Ireland
| | | | - Liliana Alvarez
- f School of Occupational Therapy, Western University , London , Canada
| | - Diane Bell
- g World Health Organization , Geneva , Switzerland
| | - Silvana Contepomi
- h Argentine Assistive Technology Association , Buenos Aires , Argentina
| | - Liezel Ennion Wegner
- i Department of Physiotherapy, University of Western Cape , Cape Town , South Africa
| | | | | | - Yih-Kuen Jan
- l The Department of Kinesiology and Community Health, College of Applied Health Sciences, University of Illinois at Urbana-Champaign , Champaign , IL , USA
| | - Jeanne Kagwiza
- m College of Medicine and Health Sciences, University of Rwanda , Kigali , Rwanda
| | - Natasha Layton
- n Department of Health Professions, Swinburne University , Hawthorn , Australia
| | | | - Malcolm MacLachlan
- p Assisting Living & Learning (ALL) Institute, Maynooth University , Maynooth , Ireland
| | | | - Cecilia Pettersson
- q Department of Architecture and Civil Engineering, Chalmers University of Technology , Goteborg , Sweden
| | - Thais Pousada
- r Faculty of Health Sciences, of A Coruña , A Coruña , Spain
| | - Elsje Scheffler
- s Centre for Rehabilitation Studies, Stellenbosch University , Stellenbosch , South Africa
| | - Sam Wu
- t Geisinger Health System , Danville , CA , USA
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116
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Goodspeed K, Newsom C, Morris MA, Powell C, Evans P, Golla S. Pitt-Hopkins Syndrome: A Review of Current Literature, Clinical Approach, and 23-Patient Case Series. J Child Neurol 2018; 33:233-244. [PMID: 29318938 PMCID: PMC5922265 DOI: 10.1177/0883073817750490] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Pitt-Hopkins syndrome (PTHS) is a rare, genetic disorder caused by a molecular variant of TCF4 which is involved in embryologic neuronal differentiation. PTHS is characterized by syndromic facies, psychomotor delay, and intellectual disability. Other associated features include early-onset myopia, seizures, constipation, and hyperventilation-apneic spells. Many also meet criteria for autism spectrum disorder. Here the authors present a series of 23 PTHS patients with molecularly confirmed TCF4 variants and describe 3 unique individuals. The first carries a small deletion but does not exhibit the typical facial features nor the typical pattern of developmental delay. The second exhibits typical facial features, but has attained more advanced motor and verbal skills than other reported cases to date. The third displays typical features of PTHS, however inherited a large chromosomal duplication involving TCF4 from his unaffected father with somatic mosaicism. To the authors' knowledge, this is the first chromosomal duplication case reported to date.
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Affiliation(s)
| | - Cassandra Newsom
- University of Texas Southwestern Medical School
- Children’s Health Dallas
| | | | | | - Patricia Evans
- University of Texas Southwestern Medical School
- Children’s Health Dallas
| | - Sailaja Golla
- University of Texas Southwestern Medical School
- Children’s Health Dallas
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117
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Kuo DZ, McAllister JW, Rossignol L, Turchi RM, Stille CJ. Care Coordination for Children With Medical Complexity: Whose Care Is It, Anyway? Pediatrics 2018; 141:S224-S232. [PMID: 29496973 DOI: 10.1542/peds.2017-1284g] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
Children with medical complexity (CMC) have multiple chronic conditions and require an array of medical- and community-based providers. Dedicated care coordination is increasingly seen as key to addressing the fragmented care that CMC often encounter. Often conceptually misunderstood, care coordination is a team-driven activity that organizes and drives service integration. In this article, we examine models of care coordination and clarify related terms such as care integration and case management. The location of care coordination resources for CMC may range from direct practice provision to external organizations such as hospitals and accountable care organizations. We discuss the need for infrastructure building, design and implementation leadership, use of care coordination tools and training modules, and appropriate resource allocation under new payment models.
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Affiliation(s)
- Dennis Z Kuo
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York;
| | - Jeanne W McAllister
- Department of Pediatrics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Lisa Rossignol
- The New Mexico Disability Story, Albuquerque, New Mexico
| | - Renee M Turchi
- Department of Pediatrics, St. Christopher's Hospital for Children and Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania; and
| | - Christopher J Stille
- Department of Pediatrics, School of Medicine, University of Colorado Denver, Denver, Colorado
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118
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Feudtner C, Schall T, Nathanson P, Berry J. Ethical Framework for Risk Stratification and Mitigation Programs for Children With Medical Complexity. Pediatrics 2018; 141:S250-S258. [PMID: 29496976 DOI: 10.1542/peds.2017-1284j] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
Those in hospitals and health care systems, when designing clinical programs for children with medical complexity, often talk about needing to develop and implement a system of risk stratification. In this article, we use the framework of an ethical evaluation of a health care program to examine what this task of risk stratification might entail by identifying specific and detailed issues that require particular attention and making a series of recommendations to help ensure that programs for children with medical complexity avoid potentially ethically problematic situations and practices.
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Affiliation(s)
- Chris Feudtner
- Department of Medical Ethics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; .,Departments of Pediatrics and Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theodore Schall
- Department of Medical Ethics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Pamela Nathanson
- Department of Medical Ethics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jay Berry
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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119
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Adams S, Nicholas D, Mahant S, Weiser N, Kanani R, Boydell K, Cohen E. Care maps for children with medical complexity. Dev Med Child Neurol 2017; 59:1299-1306. [PMID: 28984353 DOI: 10.1111/dmcn.13576] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2017] [Indexed: 11/29/2022]
Abstract
AIM Children with medical complexity require multiple providers and services to keep them well and at home. A care map is a patient/family-created diagram that pictorially maps out this complex web of services. This study explored what care maps mean for families and healthcare providers to inform potential for clinical use. METHOD Parents (n=15) created care maps (hand drawn n=10 and computer-generated n=5) and participated in semi-structured interviews about the process of developing care maps and their perceived impact. Healthcare providers (n=30) reviewed the parent-created care maps and participated in semi-structured interviews. Data were analysed for themes and emerging theory using a grounded theory analytical approach. RESULTS Data analysis revealed 13 overarching themes that were further categorized into three domains: features (characteristics of care maps), functions (what care maps do), and emerging outcomes (benefits of care map use). These domains further informed a definition and a theoretical model of how care maps work. INTERPRETATION Our findings suggest that care maps may be a way of supporting patient- and family-centred care by graphically identifying and integrating experiences of the family as well as priorities for moving forward. WHAT THIS PAPER ADDS Care maps were endorsed as a useful tool by families and providers. They help healthcare providers better understand parental priorities for care. Parents can create care maps to demonstrate the complex burden of care. They are a unique visual way to incorporate narrative medicine into practice.
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Affiliation(s)
- Sherri Adams
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| | - David Nicholas
- Faculty of Social Work, University of Calgary (Edmonton Division), Edmonton, Alberta, Canada
| | - Sanjay Mahant
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,CanChild Center for Childhood Disability Research, Hamilton, Ontario, Canada
| | - Natalie Weiser
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronik Kanani
- University of Toronto, Toronto, Ontario, Canada.,North York General Hospital, Toronto, Ontario, Canada
| | - Katherine Boydell
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Black Dog Institute, University of New South Wales, Sydney, New South Wales, Australia
| | - Eyal Cohen
- The Hospital for Sick Children, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.,CanChild Center for Childhood Disability Research, Hamilton, Ontario, Canada
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120
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Murphy N. Emergency department visits for children with cerebral palsy: what triggers the call for help? Dev Med Child Neurol 2017; 59:1110. [PMID: 28832991 DOI: 10.1111/dmcn.13531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Nancy Murphy
- Pediatrics, University of Utah, Salt Lake City, UT, USA
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121
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The Medical Home at 50: Are Children With Medical Complexity the Key to Proving Its Value? Acad Pediatr 2017; 17:581-588. [PMID: 28457939 DOI: 10.1016/j.acap.2017.04.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 04/09/2017] [Accepted: 04/09/2017] [Indexed: 11/21/2022]
Abstract
The medical home has been widely promoted as a model of primary care with the potential to transform the health care delivery system. Although this model was initially focused on children with chronic conditions, the American Academy of Pediatrics has endorsed a generalization of the model, promoting the statement, "Every child deserves a medical home." Recently, other major professional and governmental organizations have embraced this more inclusive vision, and the medical home concept has been promoted in provisions of the Affordable Care Act. Yet, rigorous evaluations of the value of the medical home, within pediatrics and beyond, have been limited, and the results have been mixed. Early results from large demonstration projects in adults have generally noted modest improvements in quality without accompanying reductions in cost. At this critical period in health care, with widespread interest in health care delivery and payment reform, these results present a potential threat to the medical home. Understanding possible reasons for these early findings is crucial to sustaining the spread of the medical home beyond its first 50 years. With this aim, we review the history of the medical home and trends in child health, and we explore the concepts of value and complexity as they pertain to pediatric health care delivery. We propose that, because of the demographic characteristics and economics of child health and current policy imperatives with regard to health care, a strong value proposition for the medical home in pediatrics involves children with medical complexity.
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122
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Katkin JP, Kressly SJ, Edwards AR, Perrin JM, Kraft CA, Richerson JE, Tieder JS, Wall L, Alexander JJ, Flanagan PJ, Hudak ML, Quinonez RA, Shenkin BN, Smith TK. Guiding Principles for Team-Based Pediatric Care. Pediatrics 2017; 140:peds.2017-1489. [PMID: 28739656 DOI: 10.1542/peds.2017-1489] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The American Academy of Pediatrics (AAP) recognizes that children's unique and ever-changing needs depend on a variety of support systems. Key components of effective support systems address the needs of the child and family in the context of their home and community and are dynamic so that they reflect, monitor, and respond to changes as the needs of the child and family change. The AAP believes that team-based care involving medical providers and community partners (eg, teachers and state agencies) is a crucial and necessary component of providing high-quality care to children and their families. Team-based care builds on the foundation of the medical home by reaching out to a potentially broad array of participants in the life of a child and incorporating them into the care provided. Importantly, the AAP believes that a high-functioning team includes children and their families as essential partners. The overall goal of team-based care is to enhance communication and cooperation among the varied medical, social, and educational partners in a child's life to better meet the global needs of children and their families, helping them to achieve their best potential. In support of the team-based approach, the AAP urges stakeholders to invest in infrastructure, education, and privacy-secured technology to meet the needs of children. This statement includes limited specific examples of potential team members, including health care providers and community partners, that are meant to be illustrative and in no way represent a complete or comprehensive listing of all team members who may be of importance for a specific child and family.
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Affiliation(s)
- Julie P. Katkin
- Pediatric Pulmonary Medicine Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | | | - James M. Perrin
- Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Colleen A. Kraft
- Health Network by Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | | | - Joel S. Tieder
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children’s Hospital, Seattle, Washington
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington; and
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After the Visit: An Overview of Government and Community Programs Supporting Children with Medical Complexity. CHILDREN-BASEL 2017; 4:children4050035. [PMID: 28471395 PMCID: PMC5447993 DOI: 10.3390/children4050035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 04/24/2017] [Accepted: 04/25/2017] [Indexed: 11/29/2022]
Abstract
The optimal care of children with medical complexity (CMC) requires involvement from a network of professionals that includes physicians, nurses, ancillary service providers, and educators. Pediatric health care providers typically have early and frequent contact with the families of CMC. Therefore, they are in a unique position to connect families to developmental, educational, and psychosocial supports. This article reviews important government and community programs that support CMC living in the United States. It outlines the educational rights of children with disabilities and offers practical tips for collaborating with Early Intervention and the public school system. The article also provides an overview of financial assistance programs, respite care services, and support groups that are beneficial to CMC and their families.
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124
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Samuels C, Harris T, Gonzales T, Mosquera RA. The Case for the Use of Nurse Practitioners in the Care of Children with Medical Complexity. CHILDREN 2017. [PMCID: PMC5406683 DOI: 10.3390/children4040024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although children with medically complex illness represent less than one percent of the total pediatric population, their health care expenditures and health care system utilization far exceed the numbers of other pediatric patients. Nurse practitioners, with their educational background focused on health care promotion and education, are uniquely qualified to reduce this inequity with cost effective care. Currently, nurse practitioners are used in a variety of health care settings and can provide acute and chronic care. Incorporating nurse practitioners at each step in the care of children with medical complexity can improve the quality of life for these children and their families, increase family satisfaction and decrease costs.
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