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Albor LC, Horn PS, Venkatesan C, Ritter DM. Impact of Race in Missed Appointments in Pediatric Neurology Resident Clinic at a Large Tertiary Medical Center. J Child Neurol 2024:8830738241264432. [PMID: 39042108 DOI: 10.1177/08830738241264432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
Missed medical appointments are a common problem across specialties. The discontinuity of care leads to unplanned health care utilization, increased costs, and poor health outcomes. Previous studies evaluating pediatric epilepsy have shown significant socioeconomic barriers to care. In several specialties, resident clinic no-show rates are higher than faculty clinics because of socioeconomic barriers. We sought to understand the relationship between race, socioeconomic factors, and missed appointments in a pediatric neurology resident clinic at a large tertiary care hospital. Resident clinic encounters for 1 year were extracted and analyzed for missed appointments, socioeconomic factors, and health care utilization. We found that missed appointments occur for 1 in 5 patients and correlate with socioeconomic factors (eg, income and insurance) and race. Race was a more significant factor than socioeconomic factors for missed appointments. These results provide areas to target and track interventions to improve health outcomes in children in pediatric neurology clinics.
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Affiliation(s)
- Lauren C Albor
- Department of Pediatrics, Emory University School of Medicine and Division of Neurology, Children's Hospital of Atlanta, Atlanta, GA, USA
| | - Paul S Horn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Charu Venkatesan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David M Ritter
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Lerch SP, Hänggi R, Bussmann Y, Lörwald A. A model of contributors to a trusting patient-physician relationship: a critical review using a systematic search strategy. BMC PRIMARY CARE 2024; 25:194. [PMID: 38824511 PMCID: PMC11143600 DOI: 10.1186/s12875-024-02435-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 05/17/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND The lack of trust between patients and physicians has a variety of negative consequences. There are several theories concerning how interpersonal trust is built, and different studies have investigated trust between patients and physicians that have identified single factors as contributors to trust. However, all possible contributors to a trusting patient-physician relationship remain unclear. This review synthesizes current knowledge regarding patient-physician trust and integrates contributors to trust into a model. METHODS A systematic search was conducted using the databases MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), and Eric (Ovid). We ran simultaneous searches for a combination of the phrases: patient-physician relationship (or synonyms) and trust or psychological safety. Six-hundred and twenty-five abstracts were identified and screened using pre-defined criteria and later underwent full-text article screening. We identified contributors to trust in the eligible articles and critically assessed whether they were modifiable. RESULTS Forty-five articles were included in the review. Patient-centered factors that contributed modifiable promoters of trust included psychological factors, levels of health education and literacy, and the social environment. Physician-centered factors that added to a trusting patient-physician relationship included competence, communication, interest in the patient, caring, the provisioning of health education, and professionalism. The patient-physician alliance, time spent together, and shared decision-making also contributed to trusting relationships between patients and physicians. External contributors included institutional factors, how payments are made, and additional healthcare services. DISCUSSION Our model summarized modifiable contributors to a trusting patient-physician relationship. We found that providing sufficient time during patient-physician encounters, ensuring continuity of care, and fostering health education are promising starting points for improving trust between patients and physicians. Future research should evaluate the effectiveness of interventions that address multiple modifiable contributors to a trusting patient-physician relationship.
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Affiliation(s)
- Seraina Petra Lerch
- Faculty of Behavioural and Cultural Studies, Ruprecht Karls-University, Heidelberg, Germany.
- University Hospital of Old Age Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland.
- Institute of Medical Psychology, Heidelberg University Hospital, Bergheimer Str. 20, DE-69115, Heidelberg, Germany.
| | - Rahel Hänggi
- Institute for Medical Education, Department for Assessment and Evaluation, University of Bern, Bern, Switzerland
| | - Yara Bussmann
- Institute for Medical Education, Department for Assessment and Evaluation, University of Bern, Bern, Switzerland
| | - Andrea Lörwald
- Institute for Medical Education, Department for Assessment and Evaluation, University of Bern, Bern, Switzerland
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Swann-Thomsen HE, Sitts C, Hanks J, Tivis R. Implementing a social work care coordination model for children and youth with special health care needs in a rural-urban health system. SOCIAL WORK IN HEALTH CARE 2024; 63:188-204. [PMID: 38217440 DOI: 10.1080/00981389.2024.2304010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
This retrospective chart review examined care coordination among pediatric patients with varying levels of medical complexity who received care in a rural-urban health system. Care coordination utilization across patient acuity levels was examined for meaningful differences in frequency and duration of care coordination services. Results indicated that patients with more severe medical complexity had increased frequency and duration of care coordination services, as well as different patterns of care coordination activity utilization. This model of pediatric outpatient care coordination provides a flexible and highly targeted approach for stratification of care and services based on the needs of the individual patient.
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Affiliation(s)
| | - Claire Sitts
- St. Luke's Children's Hospital, Boise, Idaho, USA
| | - John Hanks
- St. Luke's Children's Hospital, Boise, Idaho, USA
| | - Rick Tivis
- Applied Research Division, St. Luke's Health System, Boise, Idaho, USA
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Ming DY, Wong W, Jones KA, Antonelli RC, Gujral N, Gonzales S, Rogers U, Ratliff W, Shah N, King HA. Feasibility of Implementation of a Mobile Digital Personal Health Record to Coordinate Care for Children and Youth With Special Health Care Needs in Primary Care: Protocol for a Mixed Methods Study. JMIR Res Protoc 2023; 12:e46847. [PMID: 37728977 PMCID: PMC10551780 DOI: 10.2196/46847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Electronic health record (EHR)-integrated digital personal health records (PHRs) via Fast Healthcare Interoperability Resources (FHIR) are promising digital health tools to support care coordination (CC) for children and youth with special health care needs but remain widely unadopted; as their adoption grows, mixed methods and implementation research could guide real-world implementation and evaluation. OBJECTIVE This study (1) evaluates the feasibility of an FHIR-enabled digital PHR app for CC for children and youth with special health care needs, (2) characterizes determinants of implementation, and (3) explores associations between adoption and patient- or family-reported outcomes. METHODS This nonrandomized, single-arm, prospective feasibility trial will test an FHIR-enabled digital PHR app's use among families of children and youth with special health care needs in primary care settings. Key app features are FHIR-enabled access to structured data from the child's medical record, families' abilities to longitudinally track patient- or family-centered care goals, and sharing progress toward care goals with the child's primary care provider via a clinician dashboard. We shall enroll 40 parents or caregivers of children and youth with special health care needs to use the app for 6 months. Inclusion criteria for children and youth with special health care needs are age 0-16 years; primary care at a participating site; complex needs benefiting from CC; high hospitalization risk in the next 6 months; English speaking; having requisite technology at home (internet access, Apple iOS mobile device); and an active web-based EHR patient portal account to which a parent or caregiver has full proxy access. Digital prescriptions will be used to disseminate study recruitment materials directly to eligible participants via their existing EHR patient portal accounts. We will apply an intervention mixed methods design to link quantitative and qualitative (semistructured interviews and family engagement panels with parents of children and youth with special health care needs) data and characterize implementation determinants. Two CC frameworks (Pediatric Care Coordination Framework; Patient-Centered Medical Home) and 2 evaluation frameworks (Consolidated Framework for Implementation Research; Technology Acceptance Model) provide theoretical foundations for this study. RESULTS Participant recruitment began in fall 2022, before which we identified >300 potentially eligible patients in EHR data. A family engagement panel in fall 2021 generated formative feedback from family partners. Integrated analysis of pretrial quantitative and qualitative data informed family-centered enhancements to study procedures. CONCLUSIONS Our findings will inform how to integrate an FHIR-enabled digital PHR app for children and youth with special health care needs into clinical care. Mixed methods and implementation research will help strengthen implementation in diverse clinical settings. The study is positioned to advance knowledge of how to use digital health innovations for improving care and outcomes for children and youth with special health care needs and their families. TRIAL REGISTRATION ClinicalTrials.gov NCT05513235; https://clinicaltrials.gov/study/NCT05513235. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46847.
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Affiliation(s)
- David Y Ming
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Willis Wong
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Richard C Antonelli
- Department of Pediatrics, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, United States
| | - Nitin Gujral
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Sarah Gonzales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Ursula Rogers
- AI Health, Duke University School of Medicine, Durham, NC, United States
| | - William Ratliff
- Duke Institute for Health Innovation, Duke University School of Medicine, Durham, NC, United States
| | - Nirmish Shah
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Heather A King
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veteran Affairs Health Care System, Durham, NC, United States
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Wong W, Ming D, Pateras S, Fee CH, Coleman C, Docktor M, Shah N, Antonelli R. Outcomes of End-User Testing of a Care Coordination Mobile App With Families of Children With Special Health Care Needs: Simulation Study. JMIR Form Res 2023; 7:e43993. [PMID: 37639303 PMCID: PMC10495855 DOI: 10.2196/43993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 06/16/2023] [Accepted: 06/19/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Care for children with special health care needs relies on a network of providers who work to address the medical, behavioral, developmental, educational, social, and economic needs of the child and their family. Family-directed, manually created visual depictions of care team composition (ie, care mapping) and detailed note-taking curated by caregivers (eg, care binders) have been shown to enhance care coordination for families of these children, but they are difficult to implement in clinical settings owing to a lack of integration with electronic health records and limited visibility of family-generated insights for care providers. Caremap is an electronic health record-integrated digital personal health record mobile app designed to integrate the benefits of care mapping and care binders. Currently, there is sparse literature describing end-user participation in the co-design of digital health tools. In this paper, we describe a project that evaluated the usability and proof of concept of the Caremap app through end-user simulation. OBJECTIVE This study aimed to conduct proof-of-concept testing of the Caremap app to coordinate care for children with special health care needs and explore early end-user engagement in simulation testing. The specific aims included engaging end users in app co-design via app simulation, evaluating the usability of the app using validated measures, and exploring user perspectives on how to make further improvements to the app. METHODS Caregivers of children with special health care needs were recruited to participate in a simulation exercise using Caremap to coordinate care for a simulated case of a child with complex medical and behavioral needs. Participants completed a postsimulation questionnaire adapted from 2 validated surveys: the Pediatric Integrated Care Survey (PICS) and the user version of the Mobile Application Rating Scale (uMARS). A key informant interview was also conducted with a liaison to Spanish-speaking families regarding app accessibility for non-English-speaking users. RESULTS A Caremap simulation was successfully developed in partnership with families of children with special health care needs. Overall, 38 families recruited from 19 different US states participated in the simulation exercise and completed the survey. The average rating for the survey adapted from the PICS was 4.1 (SD 0.82) out of 5, and the average rating for the adapted uMARS survey was 4 (SD 0.83) out of 5. The highest-rated app feature was the ability to track progress toward short-term, patient- and family-defined care goals. CONCLUSIONS Internet-based simulation successfully facilitated end-user engagement and feedback for a digital health care coordination app for families of children with special health care needs. The families who completed simulation with Caremap rated it highly across several domains related to care coordination. The simulation study results elucidated key areas for improvement that translated into actionable next steps in app development.
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Affiliation(s)
- Willis Wong
- Duke University School of Medicine, Durham, NC, United States
| | - David Ming
- Duke University School of Medicine, Durham, NC, United States
| | - Sara Pateras
- Boston Children's Hospital, Boston, MA, United States
| | | | | | | | - Nirmish Shah
- Duke University School of Medicine, Durham, NC, United States
| | - Richard Antonelli
- Boston Children's Hospital, Boston, MA, United States
- Department of Accountable Care and Clinical Integration, Boston Children's Hospital, Boston, MA, United States
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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Singh-Verdeflor KD, Kloster HM, Lerner C, Klitzner TS, Cushing CC, Gerber DM, Katz BJ, Chung PJ, Delgado-Martinez R, Porras-Javier L, Ia S, Wagner T, Ehlenbach ML, Warner G, Coller RJ. Barriers to and facilitators of a just-in-time adaptive intervention for respiratory illness in cerebral palsy: a qualitative study. BMJ Open 2023; 13:e074147. [PMID: 37591653 PMCID: PMC10441064 DOI: 10.1136/bmjopen-2023-074147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/04/2023] [Indexed: 08/19/2023] Open
Abstract
OBJECTIVE To understand caregiver, healthcare professional and national expert perspectives on implementation of a just-in-time adaptive intervention, RE-PACT (Respiratory Exacerbation-Plans for Action and Care Transitions) to prevent respiratory crises in severe cerebral palsy. DESIGN Qualitative research study. SETTING Paediatric complex care programmes at two academic medical institutions. PARTICIPANTS A total of n=4 focus groups were conducted with caregivers of children with severe cerebral palsy and chronic respiratory illness, n=4 with healthcare professionals, and n=1 with national experts. METHODS Participants viewed a video summarising RE-PACT, which includes action planning, mobile health surveillance of parent confidence to avoid hospitalisation and rapid clinical response at times of low confidence. Moderated discussion elicited challenges and benefits of RE-PACT's design, and inductive thematic analysis elicited implementation barriers and facilitators. RESULTS Of the 19 caregivers recruited, nearly half reported at least one hospitalisation for their child in the prior year. Healthcare professionals and national experts (n=26) included physicians, nurses, respiratory therapists, social workers and researchers. Four overarching themes and their barriers/facilitators emphasised the importance of design and interpersonal relationships balanced against health system infrastructure constraints. Intervention usefulness in crisis scenarios relies on designing action plans for intuitiveness and accuracy, and mobile health surveillance tools for integration into daily life. Trust, knowledge, empathy and adequate clinician capacity are essential components of clinical responder-caregiver relationships. CONCLUSIONS RE-PACT's identified barriers are addressable. Just-in-time adaptive interventions for cerebral palsy appear well-suited to address families' need to tailor intervention content to levels of experience, preference and competing demands.
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Affiliation(s)
| | - Heidi M Kloster
- Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Carlos Lerner
- Pediatrics, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Thomas S Klitzner
- Pediatrics, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Christopher C Cushing
- Clinical Child Psychology Program and Schiefelbusch Life Span Institute, University of Kansas, Lawrence, Kansas, USA
| | - Danielle M Gerber
- Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | - Paul J Chung
- Health Systems Science, Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California, USA
- Pediatrics, Health Policy & Management, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Roxana Delgado-Martinez
- Pediatrics, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Lorena Porras-Javier
- Pediatrics, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Siem Ia
- Pediatrics, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Teresa Wagner
- Pediatrics, UW Health American Family Children's Hospital, Madison, Wisconsin, USA
| | - Mary L Ehlenbach
- Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Gemma Warner
- Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ryan J Coller
- Pediatrics, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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Cohen E, Quartarone S, Orkin J, Moretti ME, Emdin A, Guttmann A, Willan AR, Major N, Lim A, Diaz S, Osqui L, Soscia J, Fu L, Gandhi S, Heath A, Fayed N. Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial. JAMA Pediatr 2023; 177:461-471. [PMID: 36939728 PMCID: PMC10028546 DOI: 10.1001/jamapediatrics.2023.0115] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
Abstract
Importance Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care. Objective To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care. Design, Setting, and Participants This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months. Intervention Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care. Main Outcomes and Measures Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost. Results Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01). Conclusions and Relevance The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions. Trial Registration ClinicalTrials.gov Identifier: NCT02928757.
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Affiliation(s)
- Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Samantha Quartarone
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Julia Orkin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Myla E Moretti
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Clinical Trials Unit, Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Abby Emdin
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Hospital, Toronto, Ontario, Canada
| | - Astrid Guttmann
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Edwin S.H. Leong Centre for Healthy Children, University of Toronto, Toronto, Ontario, Canada
| | - Andrew R Willan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nathalie Major
- Department of Paediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Audrey Lim
- Department of Pediatrics, Hamilton Health Sciences Centre, McMaster University, Hamilton, Ontario, Canada
| | - Sanober Diaz
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Lisa Osqui
- Provincial Council for Maternal and Child Health, Toronto, Ontario, Canada
| | - Joanna Soscia
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence M. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Anna Heath
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Department of Statistical Science, University College London, London, United Kingdom
| | - Nora Fayed
- School of Rehabilitation Therapy, Queen's University, Kingston, Ontario, Canada
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Pygott N, Hartley A, Seregni F, Ford TJ, Goodyer IM, Necula A, Banu A, Anderson JK. Research Review: Integrated healthcare for children and young people in secondary/tertiary care - a systematic review. J Child Psychol Psychiatry 2023. [PMID: 36941107 DOI: 10.1111/jcpp.13786] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 03/23/2023]
Abstract
BACKGROUND Children and young people (CYP) with comorbid physical and/or mental health conditions often struggle to receive a timely diagnosis, access specialist mental health care, and more likely to report unmet healthcare needs. Integrated healthcare is an increasingly explored model to support timely access, quality of care and better outcomes for CYP with comorbid conditions. Yet, studies evaluating the effectiveness of integrated care for paediatric populations are scarce. AIM AND METHODS This systematic review synthesises and evaluates the evidence for effectiveness and cost-effectiveness of integrated care for CYP in secondary and tertiary healthcare settings. Studies were identified through systematic searches of electronic databases: Medline, Embase, PsychINFO, Child Development and Adolescent Studies, ERIC, ASSIA and British Education Index. FINDINGS A total of 77 papers describing 67 unique studies met inclusion criteria. The findings suggest that integrated care models, particularly system of care and care coordination, improve access and user experience of care. The results on improving clinical outcomes and acute resource utilisation are mixed, largely due to the heterogeneity of studied interventions and outcome measures used. No definitive conclusion can be drawn on cost-effectiveness since studies focused mainly on costs of service delivery. The majority of studies were rated as weak by the quality appraisal tool used. CONCLUSIONS The evidence of on clinical effectiveness of integrated healthcare models for paediatric populations is limited and of moderate quality. Available evidence is tentatively encouraging, particularly in regard to access and user experience of care. Given the lack of specificity by medical groups, however, the precise model of integration should be undertaken on a best-practice basis taking the specific parameters and contexts of the health and care environment into account. Agreed practical definitions of integrated care and associated key terms, and cost-effectiveness evaluations are a priority for future research.
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Affiliation(s)
- Naomi Pygott
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Alex Hartley
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Department of Psychology, University of Bath, Bath, UK
| | - Francesca Seregni
- Department of Paediatrics, Addenbrookes Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Tamsin J Ford
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Ian M Goodyer
- Department of Psychiatry, University of Cambridge, Cambridge, UK
| | - Andreea Necula
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Arina Banu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
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9
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Imes EP, Ginnis J, Shrestha P, Simancas-Pallares MA, Divaris K. Guardian Reports of Children's Sub-optimal Oral Health Are Associated With Clinically Determined Early Childhood Caries, Unrestored Caries Lesions, and History of Toothaches. Front Public Health 2022; 9:751733. [PMID: 35004573 PMCID: PMC8739514 DOI: 10.3389/fpubh.2021.751733] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Parents'/guardians' perceptions of their children's oral health are useful proxies of their clinically determined caries status and are known to influence dental care-seeking behavior. In this study, we sought to examine (1) the social and behavioral correlates of fair/poor child oral health reported by guardians and (2) quantify the association of these reports with the prevalence of early childhood caries (ECC), unrestored caries lesions and toothaches. Methods: We used guardian-reported child oral health information (dichotomized as fair/poor vs. excellent/very good/good) obtained via a parent questionnaire that was completed for n = 7,965 participants (mean age = 52 months; range = 36-71 months) of a community-based, cross-sectional epidemiologic study of early childhood oral health in North Carolina between 2016 and 2019. Social, demographic, oral health-related behavioral data, and reports on children's history of toothaches (excluding teething) were collected in the same questionnaire. Unrestored ECC (i.e., caries lesions) was measured via clinical examinations in a subset of n = 6,328 children and was defined as the presence of one or more tooth surfaces with an ICDAS ≥ 3 caries lesion. Analyses relied on descriptive and bivariate methods, and multivariate modeling with average marginal effect (A.M.E.) estimation accounting for the clustered nature of the data. Estimates of association [prevalence ratios (PR) and adjusted marginal effects (AME) with 95% confidence intervals (CI)] were obtained via multilevel generalized linear models using Stata's svy function and accounting for the clustered nature of the data. Results: The prevalence of fair/poor oral health in this sample was 15%-it increased monotonically with children's age, was inversely associated with parents' educational attainment, and was higher among Hispanics (21%) and African Americans (15%) compared to non-Hispanic whites (11%). Brushing less than twice a day, not having a dental home, and frequently consuming sugar-containing snacks and beverages were significantly associated with worse reports (P < 0.0005). Children with fair/poor reported oral health were twice as likely to have unrestored caries lesions [prevalence ratio (PR) = 2.0; 95% confidence interval (CI) = 1.8-2.1] and 3.5 times as likely to have experienced toothaches [PR = 3.5; 95% CI = 3.1-3.9] compared to those with better reported oral health. Conclusions: Guardian reports of their children's oral health are valuable indicators of clinical and public health-important child oral health status. Those with fair/poor guardian-reported child oral health have distinguishing characteristics spanning socio-demographics, oral-health related practices, diet, and presence of a dental home.
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Affiliation(s)
- Emily P Imes
- Doctor of Dental Surgery (DSS) Curriculum, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Jeannie Ginnis
- Division of Pediatric and Public Health, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Poojan Shrestha
- Division of Pediatric and Public Health, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Miguel A Simancas-Pallares
- Division of Pediatric and Public Health, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Kimon Divaris
- Division of Pediatric and Public Health, Adams School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States.,Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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10
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Hlyva O, Rae C, Deibert S, Kamran R, Shaikh H, Thabane L, Rosenbaum P, Klassen A, Lim A. A Mixed-Methods Feasibility Study of Integrated Pediatric Complex Care: Experiences of Parents With Care and the Value of Parent Engagement in Research. FRONTIERS IN REHABILITATION SCIENCES 2021; 2:710335. [PMID: 36188846 PMCID: PMC9397898 DOI: 10.3389/fresc.2021.710335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/15/2021] [Indexed: 11/13/2022]
Abstract
Introduction: Children with medical complexity (CMC) are among the most vulnerable children in society. These children and their families face challenges of fragmented care and are at risk for poorer health outcomes. Families with CMC play a vital role in providing care and navigating the complexities of healthcare systems. It is essential to understand the best ways to engage these families in research to improve the care and optimize the health of CMC.Objectives: This study explored parent engagement within the context of a feasibility study evaluating an Integrated Tertiary Complex Care (ITCC) clinic created to support CMC closer to home. This paper aimed: (1) to understand the family experiences of care and (2) to explore parent engagement in the study.Method: This mixed-methods feasibility study included three components. First, feedback from focus groups was used to identify the common themes that informed interviews with parents. Second, one-on-one interviews were conducted with parents to explore their experience with care, such as the ITCC clinic, using an interpretative description approach. Third, the questionnaires were completed by parents at baseline and 6-months post-baseline. These questionnaires included demographic and cost information and three validated scales designed to measure the caregiver strain, family-centered care, and parental health. The recruitment rate, percentage completion of the questionnaires, and open-ended comments were used to assess parent engagement in the study.Results: The focus groups involved 24 parents, of which 19 (14 women, five men) provided comments. The findings identified the importance of Complex Care Team (CC Team) accessibility, local access, and family-centered approach to care. The challenges noted were access to homecare nursing, fatigue, and lack of respite affecting caregiver well-being. In this study, 17 parents participated in one-on-one interviews. The identified themes relevant to care experience were proximity, continuity, and coordination of care. The parents who received care through the ITCC clinic appreciated receiving care closer to home. The baseline questionnaires were completed by 44 of 77 (57%) eligible parents. Only 24 (31%) completed the 6-month questionnaire. The challenges with study recruitment and follow-up were identified.Conclusion: Family engagement was a challenging yet necessary endeavor to understand how to tailor the healthcare to meet the complex needs of families caring for CMC.
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Affiliation(s)
- Oksana Hlyva
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Charlene Rae
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Shelby Deibert
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Rakhshan Kamran
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Haniah Shaikh
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lehana Thabane
- Department of Health, Research Methods, Evidence & Impact, McMaster University, Hamilton, ON, Canada
| | - Peter Rosenbaum
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Anne Klassen
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Audrey Lim
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
- *Correspondence: Audrey Lim
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11
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Pérez-Ardanaz B, Peláez-Cantero MJ, González-Cano-Caballero M, Gutiérrez-Rodríguez L, Gómez-González AJ, Lupiáñez-Pérez I, Morales-Asencio JM, Canca-Sánchez JC. Utilization of Parallel Resources and Sociodemographic Factors in Treating Children with Complex Chronic Diseases: A Cross-Sectional Study. CHILDREN 2021; 8:children8110973. [PMID: 34828686 PMCID: PMC8624513 DOI: 10.3390/children8110973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 10/24/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022]
Abstract
Background: Children with complex chronic conditions have a high need for health and social care resources. Many parents explore parallel resources such as alternative therapies, associations, psychological support, private medical consultations, and other out-of-pocket expenses for healthcare. The use of these alternative health resources is sometimes unclear and may lead to health inequalities. To characterize the use made of alternative healthcare resources for children with complex chronic conditions. Additionally, we evaluate the influence of sociodemographic factors on the distribution of this utilization of resources; (2) Methods: Cross-sectional study. Children with complex chronic diseases were treated at a tertiary hospital in Granada, Spain in 2016. We analyzed their use of healthcare resources and socioeconomic variables. This research complies with STROBE guidelines for observational studies; (3) Results: In total, 265 children were analyzed (mean age 7.3 years, SD 4.63). A total of 105 children (39.6%) attended private consultations with specialists, and 12.1% (n = 32) of the children had additional private health insurance. One out three parents belonged to a mutual support association (n = 78), and 26% (n = 69) of the children used alternative therapies. Furthermore, 75.4% (n = 199) of the children received no psychological support. Children whose parents had a higher educational level and occupations status made greater use of parallel healthcare resources.; (4) Conclusions: A significant proportion of children used multiple health resources in addition to the public healthcare system depending on sociodemographic determinants. Studies are needed to determine whether the use of these alternative services achieves better levels of health.
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Affiliation(s)
- Bibiana Pérez-Ardanaz
- Faculty of Health Sciences, Universidad de Málaga, 29071 Málaga, Spain; (B.P.-A.); (L.G.-R.); (A.J.G.-G.); (I.L.-P.); (J.C.C.-S.)
| | | | | | - Laura Gutiérrez-Rodríguez
- Faculty of Health Sciences, Universidad de Málaga, 29071 Málaga, Spain; (B.P.-A.); (L.G.-R.); (A.J.G.-G.); (I.L.-P.); (J.C.C.-S.)
| | - Alberto José Gómez-González
- Faculty of Health Sciences, Universidad de Málaga, 29071 Málaga, Spain; (B.P.-A.); (L.G.-R.); (A.J.G.-G.); (I.L.-P.); (J.C.C.-S.)
| | - Inmaculada Lupiáñez-Pérez
- Faculty of Health Sciences, Universidad de Málaga, 29071 Málaga, Spain; (B.P.-A.); (L.G.-R.); (A.J.G.-G.); (I.L.-P.); (J.C.C.-S.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain
| | - José Miguel Morales-Asencio
- Faculty of Health Sciences, Universidad de Málaga, 29071 Málaga, Spain; (B.P.-A.); (L.G.-R.); (A.J.G.-G.); (I.L.-P.); (J.C.C.-S.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain
- Correspondence: ; Tel.: +34-951-952-833
| | - José Carlos Canca-Sánchez
- Faculty of Health Sciences, Universidad de Málaga, 29071 Málaga, Spain; (B.P.-A.); (L.G.-R.); (A.J.G.-G.); (I.L.-P.); (J.C.C.-S.)
- Instituto de Investigación Biomédica de Málaga (IBIMA), 29010 Málaga, Spain
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12
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McClain MB, Shahidullah JD, Harris B, McIntyre LL, Azad G. Reconceptualizing Educational Contexts: The Imperative for Interprofessional and Interagency Collaboration in School Psychology. SCHOOL PSYCHOLOGY REVIEW 2021. [DOI: 10.1080/2372966x.2021.1949247] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Moore EF, Gephart SM. State of the science of care coordination, rurality, and well-being for infants with single ventricle heart disease in the Interstage period, an integrative review. Heart Lung 2021; 50:720-729. [PMID: 34107397 DOI: 10.1016/j.hrtlng.2021.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/23/2021] [Accepted: 04/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ensuring the quality of interstage management of infants with single ventricle heart disease (SVHD) residing in rural communities is difficult. Tailored care coordination through parental discharge education, formal and informal care team and family communication, adequate access to healthcare, and informed provider handoffs are crucial to the infant's well-being and survival. OBJECTIVE To discuss the state of the science related to care coordination factors and infant wellbeing during the interstage period. METHODS An integrative review approach to synthesize findings across studies was used. Through constant comparative analysis, all articles were read and coded, broken down into "data bits" or key phrases. RESULTS Four major themes were inductively derived: 1) education and confidence-building, 2) communication for building relationships, 3) social work and related mental health support, and 4) availability of resources. CONCLUSIONS Despite advances in cardiac surgery and related interventions, a clear gap exists regarding care coordination factors and infant well-being, especially in rural communities.
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Affiliation(s)
- Emily F Moore
- Seattle Children's Hospital 4800 Sand point Way NE, Seattle WA 98105 MS FA.2.114; The University of Arizona College of Nursing PO Box 210203 Tucson, AZ 85721.
| | - Sheila M Gephart
- The University of Arizona College of Nursing PO Box 210203 Tucson, AZ 85721
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14
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Pulcini CD, Coller RJ, Houtrow AJ, Belardo Z, Zorc JJ. Preventing Emergency Department Visits for Children With Medical Complexity Through Ambulatory Care: A Systematic Review. Acad Pediatr 2021; 21:605-616. [PMID: 33486099 DOI: 10.1016/j.acap.2021.01.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/09/2020] [Accepted: 01/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) represent a growing population with high emergency department (ED) utilization. How to reduce preventable ED visits is poorly understood. OBJECTIVE We sought to determine what components of ambulatory care programs focused on CMC were most effective in preventing ED visits. DATA SOURCES PubMed Plus, Cochrane Central Register of Controlled Trials, Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature databases through October 2019, and hand search of bibliographies. STUDY ELIGIBILITY CRITERIA Two independent reviewers used a structured screening protocol to include English language articles summarizing studies that included CMC, emergency care, or ED utilization. Data on ED utilization were extracted. RESULTS Sixteen included studies described outpatient interventions to prevent ED utilization. Of these, studies that included 24/7 access to knowledgeable providers for acute care needs by phone (telehealth) or expedited or next-day appointments were the most consistently successful in reducing ED visits. LIMITATIONS Risk of bias was mixed across studies. The evidence base is currently small and observational nature of interventions and their evaluations limit definitive, generalizable recommendations. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Current research suggests that real-time access to knowledgeable providers and expedited appointments can prevent ED visits. Further study is needed to generalize these findings as well as investigate novel strategies such as telehealth to improve quality of care, decrease utilization, and provide cost-effective care for this vulnerable population.
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Affiliation(s)
- Christian D Pulcini
- Division of Emergency Medicine, Department of Surgery, University of Vermont (CD Pulcini), Burlington, Vt.
| | - Ryan J Coller
- Department of Pediatrics, University of Wisconsin-Madison (RJ Coller), Madison, Wis
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh (AJ Houtrow), Pittsburgh, Pa
| | - Zoe Belardo
- University of Pennsylvania (Z Belardo), Philadelphia, Pa
| | - Joseph J Zorc
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia (JJ Zorc), Philadelphia, Pa
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15
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Holt SR, Tobin DG, Whitman L, Ellman M, Moriarty JP, Doolittle B. Creating a Satisfying Continuity Clinic Experience for Primary Care Trainees. Am J Med 2021; 134:547-553. [PMID: 33385340 DOI: 10.1016/j.amjmed.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 12/17/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Stephen R Holt
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn.
| | - Daniel G Tobin
- St. Raphael's Adult Primary Care Center of Yale-New Haven Hospital, Conn
| | - Laura Whitman
- York Street Campus Primary Care Center of Yale-New Haven Hospital, Conn
| | - Matthew Ellman
- Yale Internal Medicine Associates, Yale School of Medicine, New Haven, Conn
| | - John P Moriarty
- Yale Primary Care Internal Medicine Program, Yale-New Haven Hospital, Conn
| | - Benjamin Doolittle
- Yale Internal Medicine-Pediatrics Residency Program, Yale School of Medicine, New Haven, Conn
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16
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Braun L, Steurer M, Henry D. Healthcare Utilization of Complex Chronically Ill Children Managed by a Telehealth-Based Team. Front Pediatr 2021; 9:689572. [PMID: 34222153 PMCID: PMC8242159 DOI: 10.3389/fped.2021.689572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives: Medical advances have improved survival of critically ill children, increasing the number that have substantial ongoing care needs. The first aim of this study was to compare healthcare utilization of children with complex chronic conditions across an extensive geographic area managed by a predominantly telehealth-based team (FamiLy InteGrated Healthcare Transitions-FLIGHT) compared to matched historical controls. The second aim was to identify risk factors for healthcare utilization within the FLIGHT population. Methods: We performed a retrospective cohort study of all patients enrolled in the care management team. First, we compared them to age- and technology-based matched historic controls across medical resource-utilization outcomes. Second, we used univariable and multivariable linear regression models to identify risk factors for resource utilization within the FLIGHT population. Results: Sixty-four FLIGHT patients were included, with 34 able to be matched with historic controls. FLIGHT patients had significantly fewer hospital days per year (13.6 vs. 30.3 days, p = 0.02) and shorter admissions (6.0 vs. 17.3 days, p = 0.02) compared to controls. Within the telehealth managed population, increased number of technologies was associated with more admissions per year (coefficient 0.90, CI 0.05 - 1.75) and hospital days per year (16.83, CI 1.76 - 31.90), although increased number of complex chronic conditions was not associated with an increase in utilization. Conclusion: A telehealth-based care coordination team was able to significantly decrease some metrics of healthcare utilization in a complex pediatric population. Future study is warranted into utilization of telemedicine for care coordination programs caring for children with medical complexity.
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Affiliation(s)
- Lindsay Braun
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,University of California, Benioff Children's Hospital, San Francisco, San Francisco, CA, United States
| | - Martina Steurer
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,University of California, Benioff Children's Hospital, San Francisco, San Francisco, CA, United States
| | - Duncan Henry
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, United States.,University of California, Benioff Children's Hospital, San Francisco, San Francisco, CA, United States
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17
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The Compounding Effect of Race/Ethnicity and Disability Status on Children's Health and Health Care by Geography in the United States. Med Care 2020; 58:1059-1068. [PMID: 33177369 DOI: 10.1097/mlr.0000000000001428] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to examine the potential compounding effect of race/ethnicity, and disability status on children's health and health care, stratified by selected geographies. METHODS We used the 2011/2012 NSCH and the 2012 Boston Survey of Children's Health for our compounded disparity analysis. We used VanderWheel and Knol method to first predict combined risk ratios of race/ethnicity and disability and then compared them with the observed combined risk ratios. RESULTS We demonstrated that racial/ethnic minority children with disabilities experience additional disparities in health care access outcomes that are greater than the sum of the effects from either characteristic alone. Further, we demonstrate that disparities persist across all selected geographies irrespective of whether children lived in states or metropolitan cities with the best health care systems in the United States. CONCLUSIONS Despite reform efforts, our study demonstrates that racial/ethnic minority children with disabilities experience a double burden. Given the deleterious compounded disparities, public health and social service programs at all geographical levels should prioritize identifying participants that face this and tailor programs to meet their needs.
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18
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Pankewicz A, Davis RK, Kim J, Antonelli R, Rosenberg H, Berhane Z, Turchi RM. Children With Special Needs: Social Determinants of Health and Care Coordination. Clin Pediatr (Phila) 2020; 59:1161-1168. [PMID: 32672059 DOI: 10.1177/0009922820941206] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Care coordination (CC) facilitates access to resources/services for children/youth with special health care needs (CYSHCN). We conducted a cross-sectional analysis of the 2009-2010 National Survey of CSHCN to examine socioeconomic factors related to report of receiving adequate CC services for CYSHCN. Descriptive statistics were used to describe sociodemographic characteristics of respondents and examine socioeconomic factors. Receiving adequate CC varied by socioeconomic variables including income (100% to 199% federal poverty line [FPL]; aOR [adjusted odds ratio] = 0.848; 95% CI [confidence interval] = 0.722-0.997; P < .05), insurance (uninsured; aOR = 0.446; 95% CI = 0.326-0.609; P < .0001), and marital status (never married; aOR = 0.79; 95% CI = 0.64-0.97; P < .05). More families reporting adequate CC had private insurance, non-Hispanic white ethnicity, income >400% federal poverty level, and 2-parent households. Findings suggest unmet needs in terms of adequate access or knowledge leading to insufficient provision of CC for families with the greatest needs. Further analysis identifying specific deficits and implementing strategies to address these disparities is warranted.
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Affiliation(s)
| | | | - John Kim
- Drexel University, Philadelphia, PA, USA
| | - Richard Antonelli
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Hannah Rosenberg
- Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | | | - Renee M Turchi
- Drexel University, Philadelphia, PA, USA.,St Christopher's Hospital for Children, Philadelphia, PA, USA
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19
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Work-Sampling Study of an Innovative Care Coordination Program Aimed at Children With Chronic Health Conditions. Prof Case Manag 2020; 25:324-334. [PMID: 33017368 DOI: 10.1097/ncm.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF STUDY To estimate time allocation and labor cost for care coordinators (CCs), community health workers (CHWs), and mental health workers (MHWs) to conduct care coordination tasks in a pediatric care coordination program. PRIMARY PRACTICE SETTING A public tertiary academic medical center in Chicago, IL. METHODOLOGY AND SAMPLE A work-sampling study was conducted using a text message-based survey on 5 CCs, 20 CHWs, and 4 MHWs who volunteered to participate. Workers were randomly sampled within working hours to collect information on who was the subject of interaction and what service was being delivered over a 6-month period. Time allocation of workers to different subjects and services was summarized using descriptive statistics. RESULTS Care coordinators allocated 41% of their time to managing CHW teams. Community health workers allocated 37% of time providing services directly to children and 26% to the parent/caregiver. Mental health workers allocated 16% of time providing services to children and 29% to the parent/caregiver. The care coordination program serviced 5,965 patients, with a total annual labor cost of $1,455,353. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE Community health workers spent the majority of time working with patients and their families to conduct assessments. Mental health workers primarily addressed children's needs through their caregivers. Care coordinators primarily supported CHWs in coordinating care. Results may be used to inform development of such programs by determining services most often utilized, and labor cost may be used to inform program implementation and reimbursement.
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20
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Impact of Medical Home on Health Care of Children With and Without Special Health Care Needs: Update from the 2016 National Survey of Children's Health. Matern Child Health J 2020; 23:1500-1507. [PMID: 31222602 DOI: 10.1007/s10995-019-02774-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective The medical home has been promoted as an optimal model of health care delivery for children. The purpose of this study was to examine the association between having access to a medical home and the health care experiences of children with and without special health care needs (SHCN) in the United States. Methods We analyzed data from the 2016 National Survey of Children's Health. We modeled logistic regressions to assess associations of having access to a medical home with health care experiences for 11,392 CSHCN and 38,820 non-CSHCN. Results We found that not having access to a medical home was negatively associated with preventive medical and dental care visits, greater unmet medical and dental needs, and hospital emergency room visits. Additionally, not having access to a medical home was negatively associated with the physical and oral health among CSHCN and oral health among non-CSHCN. However, we found no significant association between improved physical health status and having access to a medical home among non-CSHCN. Conclusions Results from our analysis suggest that having access to a medical home remains key determinant of improved health care experiences by CSHCN and non-CSHCN in the United States. Our findings underscore the need to develop policies and implement a more concerted program to increase access to health care delivered under the medical home model for CSHCN and non-CSHCN. Policymakers, health care administrators and physician groups can use these findings to inform future policy decisions and service delivery reforms.
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21
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Bergman DA, Keller D, Kuo DZ, Lerner C, Mansour M, Stille C, Richardson T, Rodean J, Hudak M. Costs and Use for Children With Medical Complexity in a Care Management Program. Pediatrics 2020; 145:peds.2019-2401. [PMID: 32229620 DOI: 10.1542/peds.2019-2401] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Children with medical complexity (CMC) comprise only 6% of the pediatric population, account for ∼40% of pediatric health care spending, and provide an important opportunity for cost saving. Savings in this group can have an important impact on pediatric health care costs. The objective of this study was to assess the impact of a multicenter care management program on spending and use in CMC. DESIGN AND METHODS We conducted a prospective cohort analysis of a population of 4530 CMC enrolled in a learning collaborative designed to improve care for CMC ages 0 to 21 years identified using 3M Clinical Risk Group categories 5b through 9. The primary outcome was total per-member per-year standardized spending; secondary outcomes included inpatient and emergency department (ED) spending and use. We used a 1:1 propensity score match to compare enrolled patients to eligible nonenrolled patients and statistical process control methods to analyze spending and usage rates. RESULTS Comparison with the matched group showed a 4.6% (95% confidence interval [CI]: 1.9%-7.3%) decrease in total per-member per-year spending (P < .001), a 7.7% (95% CI: 1.2%-13.5%) decrease in inpatient spending (P = .04), and an 11.6% (95% CI: 3.9%-18.4%) decrease in ED spending (P = .04). Statistical process control analysis showed a decrease in hospitalization rate and ED visits. CONCLUSIONS CMC enrolled in a learning collaborative showed significant decreases in total spending and a significant decrease in the number of hospitalizations and ED visits. Additional research is needed to determine more specific causal factors for the results and if these results are sustainable over time and replicable in other settings.
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Affiliation(s)
- David A Bergman
- Department of Pediatrics, School of Medicine, Stanford University, Stanford, California;
| | - David Keller
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Dennis Z Kuo
- Department of Pediatrics, School of Medicine, University at Buffalo, Buffalo, New York
| | | | - Mona Mansour
- Department of Pediatrics, School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Christopher Stille
- Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | | | | | - Mark Hudak
- Department of Pediatrics, College of Medicine, University of Florida, Jacksonville, Florida
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22
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Braganza SF, Tyrrell H, Rosen C, Mogilner L, Phillips A, Slovin S, Sharif I. CORNET Card Study #1: Do You See What I See? Provider Confidence in Caring for Children With Special Health Care Needs. Acad Pediatr 2020; 20:250-257. [PMID: 31627005 DOI: 10.1016/j.acap.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 10/04/2019] [Accepted: 10/10/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Understanding differences between trainee and faculty experience with and confidence caring for children with special health care needs (CSHCN) can inform pediatric resident education. METHODS Residents and faculty across the continuity research network (CORNET) reported on a consecutive series of 5 primary care encounters. Respondents answered questions about visit characteristics, patient demographics, and applied the CSHCN Screener. Respondents also reported on how confident they felt addressing the patient's health care needs over time. We dichotomized confidence at "very confident" versus all other values. We used logistic regression to describe the correlates of provider confidence managing the patient's care. RESULTS We collected data on 381 (74%) resident-patient and 137 (26%) attending-patient encounters. A higher proportion of attending encounters compared to resident encounters were with CSHCN (49% vs 39%, P < .05), including children with complex needs (17% vs 10%, P < .05). The odds of feeling "very confident" (AOR [95% CI]) was lower with increasing CSHCN score (0.61[0.51-0.72]) and was lower for resident versus attending encounters (0.39 [0.16-0.95]). Confidence was higher if the provider had previously seen that patient (2.07 [1.15-3.72]), and for well (2.50 [1.35-4.64]) or sick visits (3.18 [1.46-6.94]) (vs follow-up). Differences between residents and attending pediatricians regarding the relationship between confidence and visit characteristics for subsets of CSHCN are reported. CONCLUSION All providers felt less confident caring for CSHCN; however, for certain needs, resident confidence did not increase with level of training. The data suggest potential educational/programmatic opportunities.
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Affiliation(s)
- Sandra F Braganza
- Department of Pediatrics, Children's Hospital at Montefiore (SF Braganza), Bronx, NY.
| | - Hollyce Tyrrell
- Research and Network Coordinator, Academic Pediatric Association (H Tyrrell), McLean, Va
| | - Carolyn Rosen
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai (C Rosen, L Mogilner), New York, NY
| | - Leora Mogilner
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai (C Rosen, L Mogilner), New York, NY
| | - Ann Phillips
- Delaware Family Voices Inc. (A Phillips), Wilmington, Del
| | - Sara Slovin
- Nemours/Alfred I. duPont Hospital for Children (S Slovin), Wilmington, Del
| | - Iman Sharif
- Department of Pediatrics, New York University School of Medicine (I Sharif), Brooklyn, NY
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McNally Keehn R, Enneking B, Ramaker M, Goings M, Yang Z, Carroll A, Ciccarelli M. Family-Centered Care Coordination in an Interdisciplinary Neurodevelopmental Evaluation Clinic: Outcomes From Care Coordinator and Caregiver Reports. Front Pediatr 2020; 8:538633. [PMID: 33194884 PMCID: PMC7661956 DOI: 10.3389/fped.2020.538633] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 09/28/2020] [Indexed: 11/13/2022] Open
Abstract
Children with neurodevelopmental disabilities experience many unmet healthcare needs. Care coordination is one critical solution to addressing the substantial strain on families, local communities, and the larger healthcare system. The purpose of this study was to implement a care coordination program in an interdisciplinary pediatric neurodevelopmental evaluation clinic and examine care coordinator and caregiver outcomes. Following neurodevelopmental diagnosis, children were provided with either care coordination (CC) or care as usual (CAU). For those receiving CC, the care coordinator documented family goals and care coordination activities, outcomes, and time spent. Caregivers in both groups completed a survey measuring access to needed services and caregiver stress and empowerment following their child's evaluation (T1) and 4-6 months post-evaluation (T2). Care coordinator findings demonstrated that over 85% of family goals focused on understanding the child's diagnosis, getting needed interventions and educational support, and accessing healthcare financing programs. More than half of care coordination activities were spent on engaging and educating the family; similarly, the most time-consuming care coordination efforts were in helping families understand their child's diagnosis and meeting family's basic needs. For those children referred to needed services, 54% were enrolled in one or more service at T2. Caregivers in both the CC and CAU groups reported an increase in stress related to interactions with their child as well as increased empowerment from T1 to T2. Contrary to our hypotheses, there were no significant group-by-time interactions across caregiver-report measures. While these findings further our understanding of care coordination delivery, they diverge from previous evidence demonstrating care coordination efficacy. This study paves the way for future opportunities to evaluate what kinds of care coordination supports family need at varying times in their child's healthcare journey and how the outcomes important to all stakeholders are measured to reflect true evaluation of efficacy.
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Affiliation(s)
- Rebecca McNally Keehn
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Brett Enneking
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Margo Ramaker
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Michael Goings
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ziyi Yang
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Aaron Carroll
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Mary Ciccarelli
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
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24
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Singh V, Pinkett-Davis M, Kalb LG, Azad G, Neely J, Landa R. A preliminary study of care coordination services within a specialized outpatient setting for youth with autism spectrum disorder. INTERNATIONAL JOURNAL OF CARE COORDINATION 2019. [DOI: 10.1177/2053434519893659] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
IntroductionParents of children with autism spectrum disorder often experience high levels of stress and challenges when organizing medical and behavioral services for their child. Care coordination could alleviate these challenges, however little is known about the effectiveness of this service. This study examined the need, feasibility, and acceptability of a care coordination program.MethodsFamilies of 176 children with autism, seen at a multidisciplinary autism clinic in the United States, participated in a prospective observational study. Families received a three-month structured care coordination program and completed pre- and post-program questionnaires that probed parents’ beliefs about the need and acceptability of the program through structured and open-ended questions.ResultsMost (≥90%) parents reported both a need for care coordination and satisfaction with the program. Qualitative themes identified valuable aspects and ways to improve the program.DiscussionParents raising a child with autism spectrum disorder experience an unmet need for care coordination. When provided, parents’ demonstrated high uptake of service and high levels of satisfaction with the program.
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Affiliation(s)
| | | | - Luther G. Kalb
- Kennedy Krieger Institute, USA
- Johns Hopkins Bloomberg School of Public Health, USA
| | - Gazi Azad
- Kennedy Krieger Institute, USA
- Johns Hopkins Bloomberg School of Public Health, USA
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25
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Effects of a Care Coordination Intervention with Children with Neurodevelopmental Disabilities and Their Families. J Dev Behav Pediatr 2019; 39:471-480. [PMID: 29672338 DOI: 10.1097/dbp.0000000000000576] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
UNLABELLED : Care coordination is integral to improving the health of children and families. Using a Shared Plan of Care (SPoC) as a care coordination activity is recommended, but related research on outcomes in pediatric populations with complex medical conditions is scarce. OBJECTIVE This study explores family outcomes associated with implementation of a care coordination/SPoC intervention with a population of children with neurodevelopmental disabilities and their families. METHODS Children aged 2 to 10 years with a neurodevelopmental disability (autism spectrum disorder: 60.9%; global developmental delay/intellectual disability: 39.1%) were referred by pediatric subspecialty programs for care coordination. The intervention included previsit assessments, planned care visits, SPoC development, and 6-month care coordination. A single-group, repeated-measures design was used to evaluate model feasibility and effects on care coordination access, SPoC use, family/clinician goals and needs met, family-professional partnerships, family empowerment, and worry. Times 1 and 2 survey data were collected from a total of 70 families. RESULTS Analysis shows significant improvement in care coordination access, SPoC use, goals achieved, needs met, family empowerment, and reduced worry. There was no significant change in family-professional partnerships and reported SPoC use. CONCLUSION Findings provide preliminary evidence that a care coordination model using a family-centered, goal-oriented SPoC is a feasible and effective approach with a cohort of children with complex neurodevelopmental disorders and is associated with improved family outcomes. Replication studies are warranted and should include a control group, prolonged time period, additional validated outcome measures, and measurement of costs and professional impact.
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26
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Coller RJ, Rodean J, Linares DE, Chung PJ, Pulcini C, Hall M, Alpern E, Mosquera R, Casto E, Berry JG. Variation in Hospitalization Rates Following Emergency Department Visits in Children with Medical Complexity. J Pediatr 2019; 214:113-120.e1. [PMID: 31540760 DOI: 10.1016/j.jpeds.2019.07.034] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 06/21/2019] [Accepted: 07/11/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To evaluate factors associated with admission from emergency department (ED) encounters for children with medical complexity (CMC) and to quantify the hospital admission rate as well as variation in adjusted hospital admission rates across EDs. STUDY DESIGN Retrospective study of 271 806 visits to 37 EDs in freestanding children's hospitals from January 1, 2014, to June 30, 2017, for patients of all ages with a complex chronic condition. Associations between patient demographic, clinical, and health services characteristics and the likelihood of hospital admission were identified using generalized linear models, which were then used to calculate adjusted hospital admission rates. RESULTS Hospital admission occurred with 25.7% of ED visits. Characteristics with the greatest aOR of hospitalization were ≥3 compared with 0 prior hospitalizations in 365 days (4.7; 95% CI, 4.5-4.9), ED arrival overnight compared with during workday 3.2 (95% CI, 3.1-3.3)], and ≥6 vs 0-1 chronic conditions (1.6; 95% CI, 1.5-1.6). Adjusted hospital admission rates varied significantly (P < .001) across EDs (21.1% [10th percentile]) and 30.0% [90th percentile]). Significant variation remained when excluding low-intensity ED visits, excluding hospitalizations requiring surgery and/or intensive care, or restricting the cohort to overnight ED arrival and to children with ≥3 prior hospitalizations. CONCLUSIONS CMC are frequently admitted from the ED. Substantial variation in CMC hospital admission rates across EDs exists after case-mix adjustment.
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Affiliation(s)
- Ryan J Coller
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Deborah E Linares
- Health Resources and Services Administration, Maternal and Child Health Bureau, Office of Epidemiology and Research, Division of Research, Rockville, MD
| | - Paul J Chung
- Health Systems Science, Kaiser Permanente School of Medicine, Departments of Pediatrics and Health Policy & Management, UCLA RAND Health, RAND Corporation, Los Angeles, CA
| | - Christian Pulcini
- Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS; Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Elizabeth Alpern
- Emergency Medicine, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL
| | - Ricardo Mosquera
- Department of Pediatrics, University of Texas Medical School, Houston, TX
| | - Elizabeth Casto
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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RFID technology-enabled Markov reward process for sequencing care coordination in ambulatory care: A case study. INTERNATIONAL JOURNAL OF INFORMATION MANAGEMENT 2019. [DOI: 10.1016/j.ijinfomgt.2019.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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28
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Tannis C, Leung K, Rowland J, Cushing A, Braun M, Wilson K, Lin E. Home Visiting Program for NICU Graduates: Feasibility and Potential for Impact. JOURNAL OF SCIENTIFIC INNOVATION IN MEDICINE 2019. [DOI: 10.29024/jsim.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Moeenuddin Z, Kim-Kupfer C, Owchar E, Baker J, Duffield A, Santoro T. The Influence of Care Coordination on Patients With Special Health Care Needs in a Pediatric Residency Continuity Clinic. Glob Pediatr Health 2019; 6:2333794X19848677. [PMID: 31106252 PMCID: PMC6507326 DOI: 10.1177/2333794x19848677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 04/11/2019] [Accepted: 04/15/2019] [Indexed: 11/20/2022] Open
Abstract
This study evaluates the influence of comprehensive health care coordination for children with special health care needs (CSHCN) in a resident continuity clinic. CSHCN patients were identified from 2 resident continuity panels. Patients were eligible with a score of 2 or greater on the CSHCN screener. Interventions included extended appointment times, a binder, and direct phone access to the social worker who facilitated follow-up appointment scheduling. Data measured included completed and no-show visits for primary care and subspecialty appointments, hospitalization and emergency department visits, use of binders, and parent satisfaction surveys. Patients with a baseline CSHCN screener score ≥4 were 15.6 times more likely to keep their appointment after enrollment (P = .0035). Mental health no-show visits decreased significantly (P < .0001). The utilization of components of comprehensive team-based care coordination, even with limited resources, can improve the delivery of health care for children with complex medical needs and mental health disorders in a resident-based clinic.
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Alvey JC, Valentine K, Wilkes J, Bardsley T, Marty C, Mann K, Murphy NA. Indirect Care Utilization Among Children with Medical Complexity. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-0204-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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31
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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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32
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Cordeiro A, Davis RK, Antonelli R, Rosenberg H, Kim J, Berhane Z, Turchi R. Care Coordination for Children and Youth With Special Health Care Needs: National Survey Results. Clin Pediatr (Phila) 2018; 57:1398-1408. [PMID: 29932000 DOI: 10.1177/0009922818783501] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
We analyzed findings from the 2009-2010 National Survey of Children with Special Health Care Needs to identify associations between families with children and youth with special health care needs (CYSHCN) reporting adequate care coordination (CC) with family-provider relations, shared decision making (SDM), and child outcomes. Eligible subjects were the 98% of families asked about CC, service use, and communication. Bivariate analysis using χ2 tests were performed on binary outcome variables to determine the strength of the associations between CC and independent and dependent variables. Weighted, multivariate logistic regression models were constructed to assess independent associations of adequate CC with child outcomes and associations of SDM on adequate CC. Among families of CYSHCN asked about CC, 72% reported receiving help with CC. Of these, 55% reported receiving adequate CC. Family report of adequate CC was favorably associated with family-provider relations, child outcomes, and report of provider participation in SDM.
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Affiliation(s)
| | | | | | | | - John Kim
- 2 Drexel University, Philadelphia, PA, USA
| | | | - Renee Turchi
- 2 Drexel University, Philadelphia, PA, USA.,4 St Christopher's Hospital for Children, Philadelphia, PA, USA
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33
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Association between Practice Participation in a Pediatric-focused Medical Home Learning Collaborative and Reduction of Preventable Emergency Department Visits by Publicly-insured Children in Massachusetts. Pediatr Qual Saf 2018; 3:e097. [PMID: 30584624 PMCID: PMC6221592 DOI: 10.1097/pq9.0000000000000097] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 07/10/2018] [Indexed: 11/26/2022] Open
Abstract
Introduction: This study evaluates the impact of practice participation in a pediatric patient-centered medical home learning collaborative on preventable emergency department (ED) visits among children in MassHealth (Massachusetts Medicaid/Children’s Health Insurance Program). Methods: Claims and enrollment data were extracted for child MassHealth members (aged 3–18) comprising 2 groups: members enrolled in a group of 13 child-serving practices that participated in an intensive, 29-month long patient-centered medical home learning collaborative (intervention group), and members enrolled in a group of 12 comparison practices with roughly similar panel size, type, and geographic location (comparison group). Preventable ED visits were identified using a modified version of the New York University ED algorithm. Two analyses were then conducted: (1) a repeat cross-sectional analysis among children enrolled in intervention or comparison group practices during baseline (first half of 2011) and follow-up (second half of 2013) periods; and (2) a longitudinal analysis among a subset of children enrolled for the full study period (2011–2013). Both analyses tested whether the effect of the intervention differed for children with versus without chronic conditions (effect modification). Results: Preventable ED visits declined from baseline to follow-up among children in both intervention and comparison practices. In the cross-sectional analysis, the decrease was the same in both practice groups, and for children with versus without chronic conditions. The longitudinal analysis shows a statistically significantly greater decrease among children with chronic conditions enrolled in the intervention practices (P = 0.02). Conclusion: Children with chronic conditions might receive the greatest benefit from receiving care in a medical home setting.
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34
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Coller RJ, Klitzner TS, Lerner CF, Nelson BB, Thompson LR, Zhao Q, Saenz AA, Ia S, Flores-Vazquez J, Chung PJ. Complex Care Hospital Use and Postdischarge Coaching: A Randomized Controlled Trial. Pediatrics 2018; 142:peds.2017-4278. [PMID: 29997169 PMCID: PMC6317544 DOI: 10.1542/peds.2017-4278] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to examine the effect of a caregiver coaching intervention, Plans for Action and Care Transitions (PACT), on hospital use among children with medical complexity (CMC) within a complex care medical home at an urban tertiary medical center. METHODS PACT was an 18-month caregiver coaching intervention designed to influence key drivers of hospitalizations: (1) recognizing critical symptoms and conducting crisis plans and (2) supporting comprehensive hospital transitions. Usual care was within a complex care medical home. Primary outcomes included hospitalizations and 30-day readmissions. Secondary outcomes included total charges and mortality. Intervention effects were examined with bivariate and multivariate analyses. RESULTS From December 2014 to September 2016, 147 English- and Spanish-speaking CMC <18 years old and their caregivers were randomly assigned to PACT (n = 77) or usual care (n = 70). Most patients were Hispanic, Spanish-speaking, and publicly insured. Although in unadjusted intent-to-treat analyses, only charges were significantly reduced, both hospitalizations and charges were lower in adjusted analyses. Hospitalization rates (per 100 child-years) were 81 for PACT vs 101 for usual care (adjusted incident rate ratio: 0.61 [95% confidence interval 0.38-0.97]). Adjusted mean charges per patient were $14 206 lower in PACT. There were 0 deaths in PACT vs 4 in usual care (log-rank P = .04). CONCLUSIONS Among CMC within a complex care program, a health coaching intervention designed to identify, prevent, and manage patient-specific crises and postdischarge transitions appears to lower hospitalizations and charges. Future research should confirm findings in broader populations and care models.
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Affiliation(s)
- Ryan J. Coller
- Departments of Pediatrics, School of Medicine and Public Health, and
| | | | | | - Bergen B. Nelson
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
| | - Lindsey R. Thompson
- Departments of Pediatrics, David Geffen School of Medicine and,Children’s Discovery and Innovation Institute, University of California, Los Angeles Mattel Children’s Hospital, Los Angeles, California
| | - Qianqian Zhao
- Biostatistics and Medical Informatics, University of Wisconsin–Madison, Madison, Wisconsin
| | | | - Siem Ia
- Departments of Pediatrics, David Geffen School of Medicine and
| | | | - Paul J. Chung
- Departments of Pediatrics, David Geffen School of Medicine and,Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California;,Children’s Discovery and Innovation Institute, University of California, Los Angeles Mattel Children’s Hospital, Los Angeles, California;,RAND Health, RAND Corporation, Santa Monica, California
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35
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Cohen E, Berry JG, Sanders L, Schor EL, Wise PH. Status Complexicus? The Emergence of Pediatric Complex Care. Pediatrics 2018; 141:S202-S211. [PMID: 29496971 DOI: 10.1542/peds.2017-1284e] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/24/2022] Open
Abstract
Discourse about childhood chronic conditions has transitioned in the last decade from focusing primarily on broad groups of children with special health care needs to concentrating in large part on smaller groups of children with medical complexity (CMC). Although a variety of definitions have been applied, the term CMC has most commonly been defined as children and youth with serious chronic conditions, substantial functional limitations, increased health and other service needs, and increased health care costs. The increasing attention paid to CMC has occurred because these children are growing in impact, represent a disproportionate share of health system costs, and require policy and programmatic interventions that differ in many ways from broader groups of children with special health care needs. But will this change in focus lead to meaningful changes in outcomes for children with serious chronic diseases, or is the pediatric community simply adopting terminology with resonance in adult-focused health systems? In this article, we will explore the implications of the rapid emergence of pediatric complex care in child health services practice and research. As an emerging field, pediatric care systems should thoughtfully and rapidly develop evidence-based solutions to the new challenges of caring for CMC, including (1) clearer definitions of the target population, (2) a more appropriate incorporation of components of care that occur outside of hospitals, and (3) a more comprehensive outcomes measurement framework, including the recognition of potential limitations of cost containment as a target for improved care for CMC.
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Affiliation(s)
- Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada; .,Department of Pediatrics and Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Lee Sanders
- Center for Policy, Outcomes and Prevention (CPOP) and.,Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
| | - Edward L Schor
- Lucile Packard Foundation for Children's Health, Palo Alto, California
| | - Paul H Wise
- Center for Policy, Outcomes and Prevention (CPOP) and.,Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
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36
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Pordes E, Gordon J, Sanders LM, Cohen E. Models of Care Delivery for Children With Medical Complexity. Pediatrics 2018; 141:S212-S223. [PMID: 29496972 DOI: 10.1542/peds.2017-1284f] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [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) are a subset of children and youth with special health care needs with high resource use and health care costs. Novel care delivery models in which care coordination and other services to CMC are provided are a focus of national and local health care and policy initiatives. Current models of care for CMC can be grouped into 3 main categories: (1) primary care-centered models, (2) consultative- or comanagement-centered models, and (3) episode-based models. Each model has unique advantages and disadvantages. Evaluations of these models have demonstrated positive outcomes, but most studies have limited generalizability for broader populations of CMC. A lack of standardized outcomes and population definitions for CMC hinders assessment of the comparative effectiveness of different models of care and identification of which components of the models lead to positive outcomes. Ongoing challenges include inadequate support for family caregivers and threats to the sustainability of models of care. Collaboration among key stakeholders (patients, families, providers, payers, and policy makers) is needed to address the gaps in care and create best practice guidelines to ensure the delivery of high-value care for CMC.
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Affiliation(s)
- Elisabeth Pordes
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - John Gordon
- Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lee M Sanders
- Lucile Packard Children's Hospital and Center for Policy, Outcomes and Prevention (CPOP), Stanford University, Palo Alto, California; and
| | - Eyal Cohen
- Department of Pediatrics, The Hospital for Sick Children and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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37
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Bright D, Frintner MP, Narayan A, Turchi RM. Are Graduating Residents Trained and Prepared to Engage in Medical Home Activities in Practice? Clin Pediatr (Phila) 2018; 57:137-145. [PMID: 28952383 DOI: 10.1177/0009922817693299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A national, random sample of 1000 graduating pediatric residents was surveyed in 2014 on receipt of training in medical home activities and preparedness to engage in same in practice. Of 602 survey respondents (60% response), 71.8% reported being very/fairly knowledgeable about medical homes. Most residents (70.0% to 91.3%) reported they received training in 6 medical home activities; more than one fourth wished for more training in 4 of 6 activities. The majority (62.5% to 77.3%) reported very good/excellent perceived preparedness. Residents with continuity clinic experiences at 2 or more sites and with continuity clinic experience at a community health center were more likely to report very good/excellent preparedness in multiple medical home activities. Overall, residents feel knowledgeable, trained, and prepared to engage in medical home activities as they are leaving residency. Opportunities exist to further explore the influence of additional training in specific activities and the number and type of training site experiences on perceived preparedness.
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Affiliation(s)
- Dana Bright
- 1 American Academy of Pediatrics, Elk Grove Village, IL, USA
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38
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Looman WS, Hullsiek RL, Pryor L, Mathiason MA, Finkelstein SM. Health-Related Quality of Life Outcomes of a Telehealth Care Coordination Intervention for Children With Medical Complexity: A Randomized Controlled Trial. J Pediatr Health Care 2018; 32:63-75. [PMID: 28870494 PMCID: PMC5726936 DOI: 10.1016/j.pedhc.2017.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 11/17/2022]
Abstract
The purpose of this study was to explore health-related quality of life (HRQL) and family impact in the context of an advanced practice registered nurse-delivered telehealth care coordination intervention for children with medical complexity (CMC). This was a secondary outcomes analysis of a randomized controlled trial with 163 families of CMC in an existing medical home. HRQL and family impact were measured using the PedsQL measurement model. Bivariate and analysis of covariance analyses were conducted to explore associations at baseline and the intervention effect over 2 years. Significant predictors of Year 2 child HRQL were baseline HRQL and the presence of both neurologic impairment and technology dependence. There was no significant intervention effect on child HRQL or family impact after 24 months. Care coordination interventions for CMC may need to incorporate family system interventions for optimal outcomes in a range of quality of life domains.
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Affiliation(s)
- Wendy S. Looman
- University of Minnesota School of Nursing, 308 Harvard S.E., Minneapolis, Minnesota, 55455, USA
- Corresponding author: Wendy S. Looman 5-140 Weaver Densford Hall 308 Harvard Street SE Minneapolis, Minnesota, 55455 (612) 624-6604
| | - Robyn L. Hullsiek
- University of Minnesota Medical Center, 500 Harvard S.E., Minneapolis, MN 55455, USA
| | - Lyndsay Pryor
- University of Minnesota Medical Center, 500 Harvard S.E., Minneapolis, MN 55455, USA
| | - Michelle A. Mathiason
- University of Minnesota School of Nursing, 308 Harvard S.E., Minneapolis, Minnesota, 55455, USA
| | - Stanley M. Finkelstein
- University of Minnesota Department of Laboratory Medicine and Pathology/Health Informatics, 420 Delaware Street S.E., Minneapolis, Minnesota, 55455, USA
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Simon TD, Whitlock KB, Haaland W, Wright DR, Zhou C, Neff J, Howard W, Cartin B, Mangione-Smith R. Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity. Pediatrics 2017; 140:peds.2017-1641. [PMID: 29192004 DOI: 10.1542/peds.2017-1641] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs. METHODS Eligible CMC at Seattle Children's Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested. RESULTS Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group (n = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5-9.8] vs 1.3 [95% CI: 1.9-4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701-$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year. CONCLUSIONS Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and .,Centers for Clinical and Translational Research and
| | - Kathryn B Whitlock
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Wren Haaland
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Davene R Wright
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - John Neff
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Waylon Howard
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Brian Cartin
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
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Turchi RM, Narayan A, Esquivel M, Serwint JR. Needs Assessment for a Medical Home Curriculum for Pediatric Residents. Glob Pediatr Health 2017; 4:2333794X17740301. [PMID: 29164176 PMCID: PMC5682582 DOI: 10.1177/2333794x17740301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/09/2017] [Indexed: 11/16/2022] Open
Abstract
Several studies and the Accreditation Council for Graduate Medical Education recommend integration of medical home (MH) concepts into pediatric resident training. There is a paucity of research depicting the current landscape of pediatric resident MH education. We hypothesized formal MH curricula in pediatric residency education are limited and pediatric residency programs desire incorporating MH education into curricula. A national needs assessment of pediatric residency programs was conducted assessing inclusion of MH concepts in training. Outcomes assessed were perceived importance of including MH concepts, satisfaction of current curriculum, content taught, resources available, and barriers encountered. Fifty-six programs (28%) completed the survey, majority academic programs. Nearly 75% indicated interest in incorporating MH concepts. Fifty-one percent of programs reported faculty knowledgeable in MH concepts/implementation and 11% reported access to readily available resources. Barriers included resident schedules, faculty teaching time, funding, and not faculty priority. Pediatric program directors report interest and need for improved MH training but identify implementation barriers.
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Affiliation(s)
- Renee M. Turchi
- St. Christopher’s Hospital for Children, Philadelphia, PA, USA
- Drexel University School of Public Health, Philadelphia, PA, USA
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41
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Lail J, Fields E, Schoettker PJ. Quality Improvement Strategies for Population Management of Children With Medical Complexity. Pediatrics 2017; 140:peds.2017-0484. [PMID: 28851739 DOI: 10.1542/peds.2017-0484] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2017] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Jennifer Lail
- James M. Anderson Center for Health Systems Excellence and
| | - Elise Fields
- Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Glassgow AE, Martin MA, Caskey R, Bansa M, Gerges M, Johnson M, Marko M, Perry-Bell K, Risser HJ, Smith PJ, Van Voorhees B. An innovative health-care delivery model for children with medical complexity. J Child Health Care 2017; 21:263-272. [PMID: 29119824 DOI: 10.1177/1367493517712063] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Children with medical complexity (CMC) account for a disproportionate share of pediatric health-care utilization and cost that is largely attributable to long hospitalizations, frequent hospital readmissions, and high use of emergency departments. In response, the Centers for Medicare and Medicaid Services Health Care Innovation Center supports the development and testing of innovative health-care payment and service delivery models. The purpose of this article is to describe the CMS-funded coordinated health care for complex kids (CHECK) program, an innovative system of health-care delivery that provides improved, comprehensive, and well-coordinated services to CMC. The CHECK program uses a combination of high-tech and low-tech interventions to connect patients, stakeholders, and providers. It is anticipated that the investment in additional support services to CMC will result in improved quality of care that leads to a reduction in unnecessary inpatient hospitalizations, readmissions, and emergency department visits and a total cost savings. The CHECK program has the potential to inform future cost-effective health-care models aimed at improving the quality of life and care for CMC and their families.
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Affiliation(s)
| | - Molly A Martin
- 1 Department of Pediatrics, College of Medicine, University of Illinois, Chicago, IL, USA
| | - Rachel Caskey
- 1 Department of Pediatrics, College of Medicine, University of Illinois, Chicago, IL, USA
| | - Melishia Bansa
- 1 Department of Pediatrics, College of Medicine, University of Illinois, Chicago, IL, USA
| | - Michael Gerges
- 1 Department of Pediatrics, College of Medicine, University of Illinois, Chicago, IL, USA
| | - Mary Johnson
- 1 Department of Pediatrics, College of Medicine, University of Illinois, Chicago, IL, USA
| | - Monika Marko
- 1 Department of Pediatrics, College of Medicine, University of Illinois, Chicago, IL, USA
| | - Kenita Perry-Bell
- 1 Department of Pediatrics, College of Medicine, University of Illinois, Chicago, IL, USA
| | - Heather J Risser
- 2 Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Peter J Smith
- 3 University of Chicago, Department of Medicine, Chicago, IL, USA
| | - Benjamin Van Voorhees
- 1 Department of Pediatrics, College of Medicine, University of Illinois, Chicago, IL, USA
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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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Gaglioti AH, Barlow P, Thoma KD, Bergus GR. Integrated care coordination by an interprofessional team reduces emergency department visits and hospitalisations at an academic health centre. J Interprof Care 2017; 31:557-565. [PMID: 28726526 DOI: 10.1080/13561820.2017.1329716] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
People with chronic behavioural and physical health conditions have higher healthcare costs and mortality rates than patients with chronic physical conditions alone. As a result, there has been promotion of integrated care for this group. It is important to train primary care residents to practice in integrated models of care with interprofessional teams and to evaluate the effectiveness of integrated care models to promote high-quality care for this at-risk group. We implemented an integrated, interprofessional care management programme for adults with chronic mental and physical health needs as part of a curriculum for family medicine and family medicine psychiatry residents. We then evaluated the clinical effectiveness of this programme by describing participants' healthcare utilisation patterns pre- and post-enrolment. Patients enrolled in the programme were approximately 60-70% less likely to utilise the emergency room and 50% less likely to be admitted to the hospital after enrolment in the programme compared to before enrolment. The odds of individual attendance at outpatient primary care and mental health visits improved after enrolment. In the context of the implementation of integrated behavioural and physical healthcare in primary care, this interprofessional care management programme reduced emergency department utilisation and hospitalisations while improving utilisation of primary care and psychiatry outpatient care. Further studies should focus on replication of this model to further discern the model's cost-savings and health promotion effects.
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Affiliation(s)
- Anne H Gaglioti
- a Department of Family Medicine, National Center for Primary Care , Morehouse School of Medicine , Atlanta , Georgia , USA
| | - Patrick Barlow
- b General Internal Medicine, Department of Internal Medicine , University of Iowa Carver College of Medicine , Iowa City , Iowa , USA
| | - Kate DuChene Thoma
- c Department of Family Medicine , University of Iowa Carver College of Medicine , Iowa City , Iowa , USA
| | - George R Bergus
- c Department of Family Medicine , University of Iowa Carver College of Medicine , Iowa City , Iowa , USA
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45
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Cady RG, Belew JL. Parent Perspective on Care Coordination Services for Their Child with Medical Complexity. CHILDREN-BASEL 2017; 4:children4060045. [PMID: 28587274 PMCID: PMC5483620 DOI: 10.3390/children4060045] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/10/2017] [Accepted: 05/29/2017] [Indexed: 12/14/2022]
Abstract
The overarching goal of care coordination is communication and co-management across settings. Children with medical complexity require care from multiple services and providers, and the many benefits of care coordination on health and patient experience outcomes have been documented. Despite these findings, parents still report their greatest challenge is communication gaps. When this occurs, parents assume responsibility for aggregating and sharing health information across providers and settings. A new primary-specialty care coordination partnership model for children with medical complexity works to address these challenges and bridge communication gaps. During the first year of the new partnership, parents participated in focus groups to better understand how they perceive communication and collaboration between the providers and services delivering care for their medically complex child. Our findings from these sessions reflect the current literature and highlight additional challenges of rural families, as seen from the perspective of the parents. We found that parents appreciate when professional care coordination is provided, but this is often the exception and not the norm. Additionally, parents feel that the local health system’s inability to care for their medically complex child results in unnecessary trips to urban-based specialty care. These gaps require a system-level approach to care coordination and, consequently, new paradigms for delivery are urgently needed.
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Affiliation(s)
- Rhonda G Cady
- Gillette Children's Specialty Healthcare, St. Paul, MN, 55101 USA.
| | - John L Belew
- Gillette Children's Specialty Healthcare, St. Paul, MN, 55101 USA.
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Coller RJ, Nelson BB, Klitzner TS, Saenz AA, Shekelle PG, Lerner CF, Chung PJ. Strategies to Reduce Hospitalizations of Children With Medical Complexity Through Complex Care: Expert Perspectives. Acad Pediatr 2017; 17:381-388. [PMID: 28108374 DOI: 10.1016/j.acap.2017.01.006] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 01/06/2017] [Accepted: 01/07/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Interventions to reduce disproportionate hospital use among children with medical complexity (CMC) are needed. We conducted a rigorous, structured process to develop intervention strategies aiming to reduce hospitalizations within a complex care program population. METHODS A complex care medical home program used 1) semistructured interviews of caregivers of CMC experiencing acute, unscheduled hospitalizations and 2) literature review on preventing hospitalizations among CMC to develop key drivers for lowering hospital utilization and link them with intervention strategies. Using an adapted version of the RAND/UCLA Appropriateness Method, an expert panel rated each model for effectiveness at impacting each key driver and ultimately reducing hospitalizations. The complex care program applied these findings to select a final set of feasible intervention strategies for implementation. RESULTS Intervention strategies focused on expanding access to familiar providers, enhancing general or technical caregiver knowledge and skill, creating specific and proactive crisis or contingency plans, and improving transitions between hospital and home. Activities aimed to facilitate family-centered, flexible implementation and consideration of all of the child's environments, including school and while traveling. Tailored activities and special attention to the highest utilizing subset of CMC were also critical for these interventions. CONCLUSIONS A set of intervention strategies to reduce hospitalizations among CMC, informed by key drivers, can be created through a structured, reproducible process. Both this process and the results may be relevant to clinical programs and researchers aiming to reduce hospital utilization through the medical home for CMC.
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Affiliation(s)
- Ryan J Coller
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis.
| | - Bergen B Nelson
- Children's Hospital of Richmond at Virginia Commonwealth University, Richmond, Va
| | | | | | - Paul G Shekelle
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, Calif; RAND Health, RAND Corporation, Santa Monica, Calif; Department of Internal Medicine, West Los Angeles VA Hospital, Los Angeles, Calif
| | | | - Paul J Chung
- David Geffen School of Medicine at UCLA, Los Angeles, Calif; RAND Health, RAND Corporation, Santa Monica, Calif; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, Calif; Children's Discovery & Innovation Institute, Mattel Children's Hospital, Los Angeles, Calif
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Abstract
Children with medical complexity have extensive needs for health services, experience functional limitations, and are high resource utilizers. Addressing the needs of this population to achieve high-value health care requires optimizing care within the medical home and medical neighborhood. Opportunities exist for health care providers, payers, and policy makers to develop strategies to enhance care delivery and to decrease costs. Important outcomes include decreasing unplanned hospital admissions, decreasing emergency department use, ensuring access to health services, limiting out-of-pocket expenses for families, and improving patient and family experiences, quality of life, and satisfaction with care. This report describes the population of children with medical complexity and provides strategies to optimize medical and health outcomes.
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48
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Nelson BB, Coller RJ, Saenz AA, Chung PJ, Kaplan A, Lerner CF, Klitzner TS. How Avoidable are Hospitalizations for Children With Medical Complexity? Understanding Parent Perspectives. Acad Pediatr 2016; 16:579-86. [PMID: 27142492 DOI: 10.1016/j.acap.2016.04.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 04/21/2016] [Accepted: 04/21/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Children with medical complexity (CMC) are a small group that utilizes large amounts of health care resources. Although parents are the primary healthcare decision-makers for their children, little is known from their perspective about why CMC are hospitalized. We sought to understand what parents think about factors leading to hospitalization and whether any recent hospitalizations might have been avoidable. METHODS We conducted qualitative, semistructured interviews with 35 parents of hospitalized CMC who receive care in the Pediatric Medical Home Program, a complex care program at University of California, Los Angeles. Interviews were conducted in English and in Spanish, audio-recorded, transcribed and translated, then coded in ATLAS.ti (Scientific Software Development Gmbh, Berlin, Germany) for qualitative analysis. We sorted qualitative codes into groups with shared concepts, to generate emergent themes. RESULTS Parents described their experiences leading up to their children's hospitalization, but no one suggested that the hospitalization was potentially avoidable. Most parents perceived their children as having higher susceptibility because of underlying conditions, perceived the symptoms they observed as high-risk, and described seeking emergent care only when they no longer were comfortable at home. Decisions about where to seek care were influenced by health care system factors such as accessibility and continuity of care. Most parents expressed a desire to learn more about their children's conditions and how best to care for them at home. CONCLUSIONS Parents of CMC believe that hospitalizations are largely unavoidable because of higher susceptibility and higher risk. Increasing parents' self-efficacy in caring for children at home might influence their decisions to seek emergent care.
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Affiliation(s)
- Bergen B Nelson
- Department of Pediatrics and Children's Discovery and Innovation Institute, Mattel Children's Hospital and David Geffen School of Medicine, University of California, Los Angeles, Calif.
| | - Ryan J Coller
- University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Adrianna A Saenz
- Department of Pediatrics and Children's Discovery and Innovation Institute, Mattel Children's Hospital and David Geffen School of Medicine, University of California, Los Angeles, Calif
| | - Paul J Chung
- Department of Pediatrics and Children's Discovery and Innovation Institute, Mattel Children's Hospital and David Geffen School of Medicine, University of California, Los Angeles, Calif; Department of Health Policy and Management, Fielding School of Public Health at UCLA, University of California, Los Angeles, Calif; RAND Health, RAND Corporation, Santa Monica, Calif
| | - Avery Kaplan
- University of Southern California, Los Angeles, Calif
| | - Carlos F Lerner
- Department of Pediatrics and Children's Discovery and Innovation Institute, Mattel Children's Hospital and David Geffen School of Medicine, University of California, Los Angeles, Calif
| | - Thomas S Klitzner
- Department of Pediatrics and Children's Discovery and Innovation Institute, Mattel Children's Hospital and David Geffen School of Medicine, University of California, Los Angeles, Calif
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Davis AM, McFadden SE, Patterson BL, Barkin SL. Strategies to identify and stratify children with special health care needs in outpatient general pediatrics settings. Matern Child Health J 2016; 19:1384-92. [PMID: 25467179 DOI: 10.1007/s10995-014-1644-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Developing improved systems of care for children with special health care needs (CSHCN) requires accurate identification and stratification of this population. This study was designed to assess the ability of a brief screener to identify and stratify CSHCN in a primary care clinic to focus future quality improvement initiatives and allocate resources. All families presenting for health maintenance visits or acute care appointments at an academic primary care clinic between September 5, 2012 and September 28, 2012 were asked to complete the CSHCN Screener(©). This panel of patients was compared to registries previously created by: (1) retrospective chart reviews using published lists of International Statistical Classification of Diseases and Related Health Problems (ICD9) codes for CSHCN and (2) direct physician referral to a clinic case manager providing care coordination services to CSHCN. Screeners identified 246 CSHCN (16.8 % of unique completed screeners). Scores ranged from 0 to 5; higher scores indicate higher levels of complexity. Patients with positive screens had a mean score of 2.4. Patients previously identified by retrospective ICD9 search who completed a screener had a mean score of 1.6 with nearly one-half having negative screens. Patients previously identified by physician referral who completed a screener had a mean score of 2.7 with nearly one-half having scores of 4 or 5. The CSHCN Screener(©) can be utilized in an academic primary care clinic to prospectively identify CSHCN and potentially offers a more clinically meaningful method of identification given its inherent ability to stratify this population based on complexity of medical needs.
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Affiliation(s)
- Alaina M Davis
- Division of General Pediatrics, Department of Pediatrics, Monroe Carell Junior Children's Hospital, Vanderbilt University School of Medicine, 2200 Children's Way, DOT 8242, Nashville, TN, 37232-9225, USA,
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50
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Health Services and Health Care Needs Fulfilled by Structured Clinical Programs for Children with Medical Complexity. J Pediatr 2016; 169:291-6.e1. [PMID: 26526361 PMCID: PMC4729644 DOI: 10.1016/j.jpeds.2015.10.010] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Revised: 08/24/2015] [Accepted: 10/02/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To describe family-reported health service needs of children with medical complexity (CMC) and to assess which needs are more often addressed in a tertiary care center-based structured clinical program for CMC. STUDY DESIGN Mailed survey to families of CMC enrolled in a structured-care program providing care coordination and oversight at 1 of 3 children's hospitals. Outcomes included receipt of 14 specific health service needs. Paired t tests compared unmet health care needs prior to and following program enrollment. RESULTS Four hundred forty-one of 968 (46%) surveys were returned and analyzed. Respondents reported their children had a mean age of 7 (SD 5) years. A majority of respondents reported the child had developmental delay (79%) and feeding difficulties (64%). Of the respondents, 56% regarded the primary care provider as the primary point of contact for medical issues. Respondents reported an increase in meeting all 14 health services needs after enrollment in a tertiary care center-based structured clinical program, including primary care checkups (82% vs 96%), therapies (78% vs 91%), mental health care (34% vs 58%), respite care (56% vs 75%), and referrals (51% vs 83%) (all P < .001). CONCLUSIONS Tertiary care center-based structured clinical care programs for CMC may address and fulfill a broad range of health service needs that are not met in the primary care setting.
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