Models of Care Delivery for Children With Medical Complexity

Financing the "Village": Establishing a Sustainable Financial System for Child Behavioral Health

An increased need for child and adolescent behavioral health services compounded by a long-standing professional workforce shortage frames our discussion on how behavioral health services can be sustainably delivered and financed. This article provides an overview of different payment models, such as traditional fee-for-service and alternatives like provider salary, global payments, and pay for performance models. It discusses the advantages and drawbacks of each model, emphasizing the need to transition toward value-based care to improve health care quality and control costs.

A Cross-Sectional Study of Disparities in Healthcare Transition in Cerebral Palsy

Background: Cerebral palsy (CP) is the most common physical disability among children, affecting their lifespan. While CP is typically nonprogressive, symptoms can worsen over time. With advancements in healthcare, more children with CP are reaching adulthood, creating a greater demand for adult care. However, a significant lack of adult healthcare providers exists, as CP is predominantly considered a pediatric condition. This study compares the transition experiences of children with CP compared to those with other developmental disabilities (DDs) and typically developing children (TDC). Methods: This study utilizes cross-sectional data from the National Survey of Children's Health (NSCH) from 2016-2020, including 71,973 respondents aged 12-17. Children were categorized into three groups: CP (n = 263), DD (n = 9460), and TDC (n = 36,053). The analysis focused on the receipt of transition services and identified demographic and socioeconomic factors influencing these services. Results: Only 9.7% of children with CP received necessary transition services, compared to 19.7% of children with DDs and 19.0% of TDC. Older age, female sex, non-Hispanic white ethnicity, and higher household income were significant predictors of receiving transition services. Children with CP were less likely to have private time with healthcare providers and receive skills development assistance compared to other groups. Conclusions: The findings highlight disparities and critical needs for targeted interventions and structured transition programs to improve the transition from pediatric to adult healthcare for children with CP. Addressing disparities in service receipt and ensuring coordinated, continuous care are essential for improving outcomes for children with CP.

The Clinical Definition of Children With Medical Complexity: A Modified Delphi Study

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) comprise a subgroup of children with severe chronic diseases. A conceptual definition for CMC has been formulated, but there is no agreement on criteria to fulfill each of the 4 proposed domains: diagnostic conditions, functional limitations, health care use, and family-identified needs. Our objective with this study was to identify a standardized definition of CMC.

METHODS

Through a scoping review of the CMC literature, we identified potential criteria to fulfill each domain. These were incorporated into an electronic survey that was completed by a geographic and professionally varied panel of 81 American and Canadian respondents with expertise in managing CMC (response rate 70%) as part of a 4-iteration Delphi procedure. Respondents were asked to vote for the inclusion of each criterion in the definition, and for those with quantitative components (eg, hospitalization rates), to generate a consensus threshold value for meeting that criterion. The final criteria were analyzed by a committee and collapsed when situations of redundancy arose.

RESULTS

Of 1411 studies considered, 132 informed 55 criteria for the initial survey, which was presented to 81 respondents. Consensus for inclusion was reached on 48 criteria and for exclusion on 1 criterion. The committee collapsed those 48 criteria into 39 final criteria, 1 for diagnostic conditions, 2 for functional limitations, 13 for health care use, and 23 for family needs.

CONCLUSIONS

These results represent the first consensus-based, standardized definition of CMC. Standardized identification is needed to advance understanding of their epidemiology and outcomes, as well as to rigorously study treatment strategies and care models.

Access to Home- and Community-Based Services for Children with Disability: Academic Institutions' Role and Areas for Improvement

OBJECTIVE

This project sought to describe provider- and parent-identified needs and barriers to obtaining home- and community-based services (HCBS) for children with disability (CWD) and to determine ways pediatric health care institutions can improve access to HCBS services.

METHODS

In this exploratory sequential mixed methods evaluation, semi-structured interviews and focus groups were conducted with multidisciplinary providers and staff from an independent children's hospital, followed by a survey of English and Spanish-speaking parents of CWD. Data from interviews and surveys were then triangulated for overarching common themes regarding how pediatric health care institutions can better support access to HCBS.

RESULTS

Among 382 parent respondents, 74.1% reported that their child needed a HCBS, most commonly physical/occupational/speech therapies, school-based support, and case management services. Two-thirds of parents reported at least one barrier to accessing HCBS and one-third experience >3 barriers. While multiple current institutional strengths were noted, internal weaknesses included lack of provider knowledge, staffing difficulties, and lack of protocols for identifying and tracking patients needing or receiving HCBS. External threats included requirements to entry for HCBS and transfer of care, with opportunities for improvement involving dissemination of information, funding support, and connection between providers/support staff and services.

CONCLUSIONS

Parents of CWD identified HCBS as necessary for the health of this population, but multiple barriers to HCBS were identified by both parents and providers. Multiple internal and external opportunities for improvement relative to pediatric health care institutions were identified, suggesting a need for a comprehensive approach to ensure that CWD receive necessary HCBS.

Coordination of family's care in an evidence-based nurse home visiting program

Interprofessional care coordination within evidence-based prevention programs like Nurse-Family Partnership® (NFP) is necessary to meet family needs and maximize program impact. This study aimed to describe the coordination of families' care in the NFP home visiting context. We used an adapted grounded theory approach and purposively sampled seven NFP sites. We conducted telephone interviews with 95 participants: 51 NFP staff (54%), 39 healthcare providers (41%), and 5 social service providers (5%). All interviews were recorded, transcribed, validated, and analyzed in NVivo11. Many community providers in all sites described their knowledge of the characteristics of the NFP intervention, including the strength of its evidence to achieve outcomes. Care coordination was dynamic and changed over time based on client needs and staff willingness to work together. Effective care coordination in the NFP context from the provider perspective is driven by shared knowledge, integrated systems, mission alignment, and individual champions who value the program.

Navigating Difficult Conversations in Caring for Children with Medical Complexity

Pediatricians are faced with a multitude of difficult tasks each day for a variety of age groups. Providing medical care and support to children with medical complexity and their families adds additional challenges, including management of polypharmacy, therapies, complications, and difficult conversations. The relationship a family has with their pediatrician is extremely special and valuable. As such, pediatricians may find themselves guiding parents through decision-making without the proper training or tools. They may struggle with navigating the conversations to assist families in reaching a helpful conclusion. This article reviews three difficult situations that families of children with medical complexity may face and three different readily available and valuable frameworks to assist with navigating those difficult conversations. [Pediatr Ann. 2024;53(3):e99-e103.].

Care Models and Discharge Services for Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) are high health care utilizers prompting hospitals to implement care models focused on this population, yet practices have not been evaluated on a national level. Our objective with this study is to describe the presence and structure of care models and the use of discharge services for CMC admitted to freestanding children's hospitals across the nation.

METHODS

We distributed an electronic survey to 48 hospitals within the Pediatric Health Information System exploring the availability of care models and discharge services for CMC. Care models were grouped by type and number present at each institution. Discharge services were grouped by low (never, rarely), medium (sometimes), and high (most of the time, always) frequency use.

RESULTS

Of 48 eligible hospitals, 33 completed the survey (69%). There were no significant differences between responders and non-responders for both hospital and patient characteristics. Most participants identified an outpatient care model (67%), whereas 21% had no dedicated care model for CMC in the inpatient or outpatient setting. High-frequency discharge services included durable medical equipment delivery, medication delivery, and communication with outpatient provider before discharge. Low-frequency discharge services included the use of a structured handoff tool for outpatient communication, personalized access plans, inpatient team follow-up with family after discharge, and the use of discharge checklists.

CONCLUSIONS

Children's hospitals vary largely in care model structure and discharge services. Future work is needed to evaluate the associations between care models and discharge services for CMC with various health care outcomes.

Initial Health Outcomes of a Community-Based Collaboration for Children in Foster Care

Children entering foster care have complex health needs that can persist across the lifespan. Efforts to improve access to primary care services exist; however, few have been tested. This study evaluated the Missoula Foster Child Health Program, a tri-agency, community-based collaboration in Montana, to determine its impact on health outcomes for youth in care. Demographic, health outcome, and child welfare data were collected from 485 children (50 percent male, 50 percent female, aged 0-18). At program admission, children had unmet service needs, lacking a primary care provider (30 percent), a dental provider (58 percent), and required vaccinations (33 percent). Three-quarters of children had at least one health condition, and one-third had a behavioral health concern. Overall, children in the program had significant decreases in physical and behavioral health problems from admission to discharge. Older children and those with fewer placements were more likely to have positive health changes. Data are promising, representing positive health outcomes of a community-based model for children in care.

Implementing a social work care coordination model for children and youth with special health care needs in a rural-urban health system

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.

Characteristics of Long-Stay Patients in a PICU and Healthcare Resource Utilization After Discharge

OBJECTIVES

To examine the characteristics of long-stay patients (LSPs) admitted to a PICU and to investigate discharge characteristics of medical complexity among discharged LSP.

DESIGN

We performed a retrospective cohort study where clinical data were collected on all children admitted to our PICU between July 1, 2017, and January 1, 2020.

SETTING

A single-center study based at Erasmus MC Sophia Children's Hospital, a level III interdisciplinary PICU in The Netherlands, providing all pediatric and surgical subspecialties.

PATIENTS

LSP was defined as those admitted for at least 28 consecutive days.

INTERVENTIONS

None.

MEASUREMENTS

Length of PICU stay, diagnosis at admission, length of mechanical ventilation, need for extracorporeal membrane oxygenation, mortality, discharge location after PICU and hospital admission, medical technical support, medication use, and involvement of allied healthcare professionals after hospital discharge.

MAIN RESULTS

LSP represented a small proportion of total PICU patients (108 patients; 3.2%) but consumed 33% of the total admission days, 47% of all days on extracorporeal membrane oxygenation, and 38% of all days on mechanical ventilation. After discharge, most LSP could be classified as children with medical complexity (CMC) (76%); all patients received discharge medications (median 5.5; range 2-19), most patients suffered from a chronic disease (89%), leaving the hospital with one or more technological devices (82%) and required allied healthcare professional involvement after discharge (93%).

CONCLUSIONS

LSP consumes a considerable amount of resources in the PICU and its impact extends beyond the point of PICU discharge since the majority are CMC. This indicates complex care needs at home, high family needs, and a high burden on the healthcare system across hospital borders.

Advanced fellowship training for cardiology fellows in acute care cardiology

Hospitalised children have become more medically complex and increasingly require specialised teams and units properly equipped to care for them. Within paediatric cardiology, this trend, which is well demonstrated by the expansion of cardiology-specific ICUs, has more recently led to the development of acute care cardiology units to deliver team-based and condition-focused inpatient care. These care teams are now led by paediatric cardiologists with particular investment in the acute care cardiology environment. Herein, we describe the foundation and development of an Acute Care Cardiology Advanced Training Fellowship to meet the clinical, scholarly, and leadership training needs of this emerging care environment.

Understanding parents' experiences of care for children with medical complexity in England: a qualitative study

OBJECTIVES

To understand parents' experiences of receiving care for their child with medical complexity.

DESIGN

Qualitative semi-structured interviews with parents of children with medical complexities across England analysed using reflexive thematic analysis.

RESULTS

Twenty parents from four hospital sites in England took part in the study, a total of 17 interviews were completed, 3 joint and 14 single parent interviews. Four themes were developed: parents feel abandoned; continuity of care (made up of three subthemes); equipment barriers; and charities fill the gaps.

CONCLUSIONS

The perceived quality of healthcare provided to this population was found to be inconsistent, positive examples referred to continuity of care; communication, clinical management and long-lasting relationships. However, many experienced challenges when receiving care for their children; many of these challenges have been highlighted over the past two to three decades but despite the children's needs becoming more complex, little progress appears to have been made. Parents were seen as adopting significant additional roles beyond being a parent, but they still find themselves left without support across all areas. These families require more structured support. Policy makers and commissioners need to prioritise the needs of families to enable health and social care services to provide the support required.

Caregiver Perspectives on Telemedicine for Postdischarge Care for Children With Medical Complexity: A Qualitative Study

INTRODUCTION

The objectives of this study were to describe the perspectives of caregivers of children with medical complexity on telemedicine video visits (TMVV) for posthospitalization care and determine whether TMVV may be a viable alternative to in-person follow-up.

METHOD

Our qualitative descriptive study included semistructured telephone interviews with 12 caregivers. Data analysis was conducted using an adapted Colaizzi's descriptive phenomenological method for thematic construction.

RESULTS

Results were organized into four themes describing caregivers' experiences with TMVV: (1) promoted caregiver self-efficacy and sense of independence; (2) TMVV as convenient, cost-effective, comprehensive, and acceptable; (3) supported caregiver decision-making and problem-solving; and (4) fostered delivery of family-centered care.

DISCUSSION

Although in-person visits are necessary for some circumstances, TMVV can serve as a convenient and acceptable alternative for posthospitalization follow-up in children with medical complexity. Overall, caregivers in this study were satisfied with the quality of care and individualized experience of TMVV.

Provision of care for children with medical complexity in tertiary hospitals in England: qualitative interviews with health professionals

BACKGROUND

Due to medical and technological advancements, children with medical complexity are a growing population. Although previous research has identified models of care and experiences when caring for this population, the majority are the USA or Canadian based. Therefore, the aim was to identify models of care for children with medical complexity and barriers and facilitators to delivering high-quality care for this population from a 'free at point of care' national health service.

METHOD

Qualitative semistructured interviews were conducted with hospital clinicians across England and analysed using a thematic framework approach.

RESULTS

Thirty-seven clinicians from 11 hospital sites were interviewed. In 6 of the hospital sites, there were 14 services identified. Majority of services had a variety of components, some shared and some unique to the individual service. Clinicians faced barriers and facilitators when caring for this population as demonstrated across five categories.

CONCLUSIONS

There is limited guidance and evidence on the most effective and efficient models for providing care for this population. It is not possible to determine what a service should look like as there is no consensus on the most appropriate model of care as shown in this study. Due to their complex needs, this population require coordination to ensure high standards of care. However, this was not always possible as clinicians faced barriers such as time constraints, silo thinking and a lack of available housing.

Is it too complex? A survey of pediatric residency program's educational approach for the care of children with medical complexity

BACKGROUND

Although Entrustable Professional Activities (EPAs) regarding pediatric training in care for children with medical complexity (CMC) exist, it is unknown what US pediatric training programs provide for education related to care of CMC and whether educators perceive that pediatric residents are prepared to care for CMC upon graduation.

METHODS

From June, 2021 through March 2022, we surveyed US pediatric residency program delegates about practice settings, current educational offerings, perception of resident preparedness regarding care of CMC, and likelihood to implement CMC education in the future.

RESULTS

Response rate was 29% (56 /195). A third of responding programs (34%, n = 19) provide a specific educational CMC offering including combinations of traditional didactics (84%, n = 16), asynchronous modules/reading (63%, n = 12), experiential learning (58%, n = 11), and simulation-based didactics (26%, n = 5). The majority (93%, n = 52) of respondents agreed residents should be competent in providing primary care for CMC upon graduation and CMC should receive primary care from a resident (84%, n = 47). A total of 49% (n = 27) of respondents reported their residents are very or extremely well prepared to care for CMC after graduation. A total of 33% (n = 18) of programs reported CMC receive primary care from residents. Respondent average perception of resident preparedness was significantly higher in programs with educational offerings in five of eleven EPAs (nutrition and weight, transitions, feeding tubes, advocacy, and care coordination). The majority (78%, n = 29) of programs without educational offerings are at least somewhat likely to implement CMC curricula in the next three years.

CONCLUSION

Pediatric residency programs report residents should be competent in care for CMC upon graduation. Pediatric residents are exposed to a wide variety of clinical care models for CMC. The minority of responding programs have intentional CMC educational offerings. Of those programs that provide CMC education, the offerings are variable and are associated with a perception of improved preparedness to care for CMC upon graduation.

Predictive Modeling to Identify Children With Complex Health Needs At Risk for Hospitalization

BACKGROUND

Identifying children at high risk with complex health needs (CCHN) who have intersecting medical and social needs is challenging. This study's objectives were to (1) develop and evaluate an electronic health record (EHR)-based clinical predictive model ("model") for identifying high-risk CCHN and (2) compare the model's performance as a clinical decision support (CDS) to other CDS tools available for identifying high-risk CCHN.

METHODS

This retrospective cohort study included children aged 0 to 20 years with established care within a single health system. The model development/validation cohort included 33 months (January 1, 2016-September 30, 2018) and the testing cohort included 18 months (October 1, 2018-March 31, 2020) of EHR data. Machine learning methods generated a model that predicted probability (0%-100%) for hospitalization within 6 months. Model performance measures included sensitivity, positive predictive value, area under receiver-operator curve, and area under precision-recall curve. Three CDS rules for identifying high-risk CCHN were compared: (1) hospitalization probability ≥10% (model-predicted); (2) complex chronic disease classification (using Pediatric Medical Complexity Algorithm [PMCA]); and (3) previous high hospital utilization.

RESULTS

Model development and testing cohorts included 116 799 and 27 087 patients, respectively. The model demonstrated area under receiver-operator curve = 0.79 and area under precision-recall curve = 0.13. PMCA had the highest sensitivity (52.4%) and classified the most children as high risk (17.3%). Positive predictive value of the model-based CDS rule (19%) was higher than CDS based on the PMCA (1.9%) and previous hospital utilization (15%).

CONCLUSIONS

A novel EHR-based predictive model was developed and validated as a population-level CDS tool for identifying CCHN at high risk for future hospitalization.

Developing and maintaining health literacy: A continuous emotional, cognitive, and social process for parents of children with epilepsy-A qualitative study

Childhood epilepsy is often complicated by neurobehavioral comorbidities, and parents are expected to actively engage in managing the condition. Insufficient parental health literacy (HL) has been associated with reduced health outcomes for children with epilepsy. Little is known about the parents' experiences of information seeking, social support, navigating the healthcare system, and interactions with healthcare professionals and how these skills may contribute to the development of sufficient HL. This study explored parents' experiences of their caregiver responsibility and the development of their HL in relation to caring for their child with epilepsy. Ten parents of children under 12 years of age with epilepsy were purposedly sampled and interviewed individually, using semi-structured interviews. The interviews were analyzed using qualitative content analysis, in line with Graneheim & Lundman. The analyses resulted in three themes, each comprising two sub-themes. The themes were: (1) Alone with the responsibility, (2) The combat for information and support, and (3) Developing vigilance and distrust in system competence. Lack of flexibility in healthcare services, insufficient multidisciplinary collaboration, and unclear treatment provider responsibility made the parents feel alone in the caregiver's responsibility. Poor local provider competence related to childhood epilepsy was a barrier to developing sufficient HL. A trusting relationship with professionals and timely access to competent health services were facilitators for developing HL. Higher HL made the parents more critical for the healthcare services, which triggered vigilance and reduced their trust in the professionals' information. For the parents, developing and maintaining HL was a continuous emotional, cognitive, and social process. Health information and care support need to be adjusted to the severity of the child's condition, the resources are available, and the parent's HL. The results of this study may contribute to the development of future interventions for strengthening parental HL in the childhood epilepsy context.

The Effect of Neighborhood Disorganization on Care Engagement Among Children With Chronic Conditions Living in a Large Urban City

Neighborhood context plays an important role in producing and reproducing current patterns of health disparity. In particular, neighborhood disorganization affects how people engage in health care. We examined the effect of living in highly disorganized neighborhoods on care engagement, using data from the Coordinated Healthcare for Complex Kids (CHECK) program, which is a care delivery model for children with chronic conditions on Medicaid in Chicago. We retrieved demographic data from the US Census Bureau and crime data from the Chicago Police Department to estimate neighborhood-level social disorganization for the CHECK enrollees. A total of 6458 children enrolled in the CHECK between 2014 and 2017 were included in the analysis. Families living in the most disorganized neighborhoods, compared with areas with lower levels of disorganization, were less likely to engage in CHECK. Black families were less likely than Hispanic families to be engaged in the CHECK program. We discuss potential mechanisms through which disorganization affects care engagement. Understanding neighborhood context, including social disorganization, is key to developing more effective comprehensive care models.

Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial

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.

Palliative Care Needs Assessment for Pediatric Complex Care Providers

CONTEXT

Children with medical complexity (CMC) are often cared for by both complex care and palliative care pediatric teams. No prior research has investigated the relationship between these two disciplines.

OBJECTIVES

The purpose of this article is to investigate challenges that complex care programs face in caring for children with medical complexity (CMC), as well as to explore whether identified challenges could be met through collaboration with pediatric palliative care or additional training for complex care teams.

METHODS

Medical providers who self-identified as providing clinical care to children with medical complexity were asked to complete an online anonymous survey. Subjects were recruited through a Complex Care listerv. Data were analyzed using descriptive statistics.

RESULTS

85 subjects completed the survey, of whom 87.1% (n=74) were physicians, and 12.0% (n=11) were nurse practitioners. Subjects reported several challenges in caring for CMC, including symptom management, establishing goals of care, advance care planning, and coordination of care. A majority of subjects reported benefitting from palliative care consultative assistance in each subject area. Most subjects described their relationship with palliative care as a close partnership with frequent overlap.

CONCLUSIONS

The evolving field of pediatric complex care is associated with an array of challenges in caring for CMC. Many of these challenges include competency areas where palliative care providers receive concerted training. Our research suggests greater palliative care involvement in the CMC population can benefit complex care teams and patients, given the expertise palliative providers can bring to the population and the discipline of complex care.

Mindful Self-Care for Caregivers: A Proof of Concept Study Investigating a Model for Embedded Caregiver Support in a Pediatric Setting

We conducted an open-trial proof of concept study to determine the safety, acceptability, and feasibility of Mindful Self-Care for Caregivers (MSCC) for parents of children with Autism Spectrum Disorders (ASD) (N = 13). The intervention was offered as a co-located care model in a pediatric specialty center where the participants' children received care. Results demonstrated that the intervention was: highly acceptable to all stakeholders (i.e., participants, the group facilitator, and center administration) and could be conducted safely by a masters-level practitioner with minimal resources. Further, secondary measures support a hypothesized interventional model of MSCC, demonstrating gains in mindfulness skills and sense of competency in the parenting role reduced perceived stress and depression in parents of children with ASD.

Parents' process of recognition and response to clinical deterioration of their children with medical complexity at home: A grounded theory

AIM

To explore the process of recognition and response to clinical deterioration of children with medical complexity at home by their parents.

BACKGROUND

Children with medical complexity are characterised by known chronic conditions associated with frailty and functional limitations, dependence on healthcare services and high use of technology and resources. Their medical complexity often leads to the onset of complications. Targeted care ensures timely recognition and response to clinical deterioration at home, thus avoiding serious sequelae, inappropriate hospitalisations and improving quality of life. Evidence on parents' process of the recognition and response to clinical deterioration at home is limited.

DESIGN

Qualitative study using a Grounded Theory methodology.

METHOD

Seven online focus groups were conducted with parents and healthcare providers experienced in their care. The interviews were transcribed verbatim and analysed through open, axial and selective coding, using a constant comparative iterative method. The COREQ guidelines guided the reporting of this work.

RESULTS

Four categories and one core category were identified: (1) Awareness of the unique and shared characteristics of children with medical complexity; (2) Parents' care maintenance and management; (3) Parents' care monitoring; (4) Parents' response to clinical deterioration and (5) Seeking the Shift of Agency, the core category as the foundation of the Process of Recognition and rEsponse of PAREnts to Deterioration (PRE-PARE-D) theory.

CONCLUSION

The role of parents of children with medical complexity is evolving into active care leaders, by developing care management and care monitoring competences and negotiating care with healthcare providers.

RELEVANCE TO CLINICAL PRACTICE

The shift of agency from healthcare providers to parents requires education and counselling pathways to promote the development of parent's self-efficacy, competencies and empowerment in the care management of their children. Home care delivery for children with medical complexity should aim at sustaining this partnership between healthcare providers and parents.

Parent-to-parent peer support for children and youth with special health care needs: Preliminary evaluation of a family partner program in a healthcare system

PURPOSE

Children and youth with special health care needs (CYSHCN) have complex care and coordination needs that are often managed by parents or primary caregivers. This study describes a parent-to-parent peer support pilot program for parents of CYSHCN implemented in both outpatient and inpatient settings across a large health system.

DESIGN & METHODS

Retrospective data from the Family Partner Program documentation in patient health records are described. Descriptions about the encounters and types of support provided are also reviewed using qualitative descriptive analysis.

RESULTS

Three Family Partners conducted 203 encounters with parents of 90 CYSHCN over six months. Family Partners provided both emotional and tangible support. Primary themes discussed included the persistent care, coordination and management needs related to parenting a child with complex care needs, the subsequent worry and stress about their child and family, and the need for stress management and self-care.

CONCLUSION

This study provides early evidence that implementation of a parent-to-parent peer support program for parents of CYSHCN in a large, academic medical center is feasible. Family Partners enhanced their healthcare team's ability to provide patient- and family-centered support for pediatric patients and their families through the provision of emotional and tangible support.

PRACTICE IMPLICATIONS

Family Partners, who are trained in effective use of the shared experience, the health coach model, and healthcare systems, and who are supported by a strong supervisory team, are ideally suited to support families and patients as they address their concerns and unmet needs and navigate complex health circumstances.

Demographic and Clinical Differences Between Applied Definitions of Medical Complexity

OBJECTIVES

To identify the degree of concordance and characterize demographic and clinical differences between commonly used definitions of multisystem medical complexity in children hospitalized in children's hospitals.

METHODS

We conducted a retrospective, cross-sectional cohort study of children <21 years of age hospitalized at 47 US Pediatric Health Information System-participating children's hospitals between January 2017 to December 2019. We classified patients as having multisystem complexity when using 3 definitions of medical complexity (pediatric complex chronic conditions, pediatric medical complexity algorithm, and pediatric chronic critical illness) and assessed their overlap. We compared demographic, clinical, outcome, cost characteristics, and longitudinal healthcare utilization for each grouping.

RESULTS

Nearly one-fourth (23.5%) of children hospitalized at Pediatric Health Information System-participating institutions were identified as meeting at least 1 definition of multisystem complexity. Children with multisystem complexity ranged from 1.0% to 22.1% of hospitalized children, depending on the definition, with 31.2% to 95.9% requiring an ICU stay during their index admission. Differences were seen in demographic, clinical, and resource utilization patterns across the definitions. Definitions of multisystem complexity demonstrated poor agreement (Fleiss' κ 0.21), with 3.5% of identified children meeting all 3.

CONCLUSIONS

Three definitions of multisystem complexity identified varied populations of children with complex medical needs, with poor overall agreement. Careful consideration is required when applying definitions of medical complexity in health services research, and their lack of concordance should result in caution in the interpretation of research using differing definitions of medical complexity.

Access to Services for Children and Youth With Special Health Care Needs and Their Families: Concepts and Considerations for an Integrated Systems Redesign

Access to services for children and youth with special health care needs (CYSHCN) have typically emphasized coverage, service, timeliness, and capability. Yet families of CYSHCN continue to describe a fragmented health care system with significant unmet needs. For many years, the concept of access to services has focused on the services themselves, rather than starting with the needs of CYSHCN and their families. Meeting these needs should be grounded in health equity, address systemic racism and ableism, and emphasize the life course and journey of those with such needs and their families. In this paper, we start with the simple concept of asking that care is available for CYSHCN regardless of when, where, and how they need it. Access to services is built on relationships instead of a series of transactions. Opportunities for innovation include creating a single point of service entry; determining services based on need instead of diagnosis; and emphasizing service continuity, transition, and a place-based approach. The innovations reimagine access throughout the life course, centering care around a proactive, human-centered system that addresses health and all of its determinants. The landscape of antipoverty investments, cultural humility, workforce changes, technology, and human-centered thought in design have the potential to further transform the conceptual framework to improve access to services for CYSHCN and their families.

Guidance for Structuring a Pediatric Intermediate Care Unit

The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.

Patient, Caregiver, and Clinician Participation in Prioritization of Research Questions in Pediatric Hospital Medicine

IMPORTANCE

The research agenda in pediatric hospital medicine has seldom considered the perspectives of young people, parents and caregivers, and health care professionals. Their perspectives may be useful in identifying questions on topics for research.

OBJECTIVE

To prioritize unanswered research questions in pediatric hospital medicine from the perspectives of young people, parents/caregivers, and health care professionals.

DESIGN, SETTING, AND PARTICIPANTS

Between August 4, 2020, and August 19, 2021, two online surveys and a virtual workshop were conducted, using modified Delphi technique and nominal group technique. Young people, parents/caregivers, and health care professionals with experiences in pediatric hospital medicine in Canada were included.

INTERVENTIONS

The established James Lind Alliance Priority Setting Partnership method was used. In phase 1, a survey collected unanswered questions regarding pediatric hospital medicine via 3 open-ended questions. Survey responses were used to develop summary questions that went through an evidence-checking process. Unanswered questions were brought to a phase 2 interim prioritization survey. The top 10 unanswered research questions in pediatric hospital medicine were established at the final priority setting workshop.

MAIN OUTCOMES AND MEASURES

Survey responses, top 10 research questions.

RESULTS

The phase 1 survey was completed by 188 participants (148 of 167 [89%] females; 17 of 167 [10%] males; mean [SD] age, 39.5 [12.4] years) and generated 495 unanswered research questions and comments, of which 58 were deemed out of scope. The remaining 437 responses were grouped into themes (eg, communication, shared decision-making, health service delivery, and health service management) and then refined to 75 unanswered research questions. Of these 75, only 4 questions had sufficient evidence. To make the number of questions in phase 2 manageable, 21 questions submitted by only 1 respondent were eliminated. Fifty unanswered research questions were included in the phase 2 survey, which was completed by 201 participants (165 of 186 [89%] females; 19 of 186 [10%] males; mean [SD] age, 40.0 [11.0] years). A short list of 16 questions-the top 10 questions from patient partners (youths, parents/caregivers) and clinicians-was presented at the final priority setting workshop and the top 10 questions were prioritized. The top 10 questions focused on the care of special inpatient populations (eg, children with medical complexity), communication, shared decision-making, support strategies in the hospital, mental health supports, shortening length of stay, and supporting Indigenous patients, parents/caregivers, and families.

CONCLUSIONS AND RELEVANCE

This patient-oriented pediatric hospital medicine priority setting partnership identified the most important unanswered research questions focused on the care of children in the hospital. These questions provide a possible roadmap for research on areas deemed important to young people, parents/caregivers, and clinicians.

Feasibility of Post-hospitalization Telemedicine Video Visits for Children With Medical Complexity

OBJECTIVES

To evaluate feasibility and acceptability of post-hospitalization telemedicine video visits (TMVV) during hospital-to-home transitions for children with medical complexity (CMC); and explore associations with hospital utilization, caregiver self-efficacy (CSE), and family self-management (FSM).

METHOD

This non-randomized pilot study assigned CMC (n=28) to weekly TMVV for four weeks post-hospitalization; control CMC (n=20) received usual care without telemedicine. Feasibility was measured by time to connection and proportion of TMVV completed; acceptability was measured by parent-reported surveys. Pre/post-discharge changes in CSE, FSM, and hospital utilization were assessed.

RESULTS

64 TMVV were completed; 82 % of patients completed 1 TMVV; 54 % completed four TMVV. Median time to TMVV connection was 1 minute (IQR=2.5). Parents reported high acceptability of TMVV (mean 6.42; 1 -7 scale). CSE and FSM pre/post-discharge were similar for both groups; utilization declined in both groups post-discharge.

DISCUSSION

Post-hospitalization TMVV for CMC were feasible and acceptable during hospital-to-home transitions.

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

OBJECTIVE

Children and youth with special health care needs (CYSHCN) have a range of medical, educational, and support service needs to achieve optimal health and wellness. Principles of care for CYSHCN have been well described, but the literature is lacking particularly on implementation and integration of care across different settings and systems. The objective of this manuscript is to define a research agenda for principles of care for CYSHCN.

METHODS

Literature review examined principles of care for CYSHCN. Existing research gaps and priorities for principles of care were drawn from the literature review, a recently developed national research agenda for CYSHCN, and stakeholder consensus.

RESULTS

Specific implementation areas of inquiry include family partner roles within and across systems; life course approach for CYSHCN; roles and training of interdisciplinary team members; and implementation, spread, and sustainability studies. Proposed methods include implementation science-based and comparative effectiveness research. A common set of metrics including health care utilization, clinical outcomes, and family and provider needs should be considered to evaluate implementation of principles of care.

CONCLUSIONS

Implementation science and comparative effectiveness methods are needed to further understanding about how to adopt and spread principles of care for CYSHCN. The evolving demographics of CYSHCN add relevance and urgency for research findings.

The Mental and Physical Health of Mothers of Children with Special Health Care Needs in the United States

OBJECTIVE

To determine the prevalence of poor mental and physical health among mothers of children with special health care needs (CSHCN) and to determine the association between maternal health and the child's number of special health care needs (SHCN) and severity of ability limitation.

METHODS

We used the combined 2016-2018 National Survey of Children's Health Dataset of 102,341 children ages 0-17 including 23,280 CSHCN. We used regression models to examine the associations of a child's number of SHCN and ability limitations with maternal health.

RESULTS

Twice as many mothers of CSHCN had poor mental and physical health compared to non-CSHCN (mental 10.3% vs. 4.0%, p < .001; physical 11.9% vs 5.0%, p < .001). In regression models, increased number of SHCN and severity of activity limitations were associated with significantly increased odds of poor maternal health.

CONCLUSIONS FOR PRACTICE

Mothers of CSHCN have worse health compared to mothers of non-CSHCN, especially those who experience social disadvantage and those with children with complex SHCN or severe ability limitations. Interventions to improve the health of these particularly vulnerable caregivers of CSHCN are warranted.

A Qualitative Study of Family Caregiver Perceptions of High-Quality Care at a Pediatric Complex Care Center

OBJECTIVE

Pediatric complex care centers are an increasingly common approach to address the needs of children with medical complexity (CMC). We sought to better understand CMC caregivers' perceptions of what constitutes high-quality care at a complex care center.

METHODS

We conducted a cross-sectional qualitative study of family caregivers of CMC receiving care at a pediatric complex care center situated within a tertiary-care children's hospital. In-depth, semistructured interviews focused on caregivers' general experiences at the clinic, positive and negative experiences related to core components of the pediatric medical home, and recommendations for improvements. We thematically analyzed transcripts through a mixed inductive and deductive approach, using constant comparative methodology, with the pediatric medical home model as an organizing framework.

RESULTS

We conducted interviews with 20 participants (18 [90%] biological parents; 19 [95%] female; mean age 39 years) in outpatient settings. Caregivers described 2 major themes: 1) the value of having a clinician "quarterback" who is in-charge of their child's care and caregivers' go-to for questions and concerns, and 2) wanting clinicians who are personally invested in and willing to "go above and beyond" for their child. Participants discussed how and which components of the medical home model enable CMC clinicians to meet these needs.

CONCLUSIONS

Family caregivers of CMC want clinicians who take responsibility for managing their child's overall care and demonstrate personal commitment to ensuring their child's well-being. Multiple aspects of the medical home framework, rather than care coordination alone, help meet caregivers' perceptions of high-quality complex care.

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

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

Feasibility of implementing systematic social needs assessment for children with medical complexity

Background

Children with medical complexity (CMC) have inter-related health and social needs; however, interventions to identify and respond to social needs have not been adapted for CMC. The objective of this study was to evaluate the feasibility of implementing social needs screening and assessment within pediatric complex care programs.

Methods

We implemented systematic social needs assessment for CMC (SSNAC) at two tertiary care centers in three phases: (1) pre-implementation, (2) implementation, and (3) implementation monitoring. We utilized a multifaceted implementation package consisting of discrete implementation strategies within each phase. In phase 1, we adapted questions from evidence-informed screening tools into a 21-item SSNAC questionnaire, and we used published frameworks to inform implementation readiness and process. In phases 2–3, clinical staff deployed the SSNAC questionnaire to parents of CMC in-person or by phone as part of usual care and adapted to local clinical workflows. Staff used shared decision-making with parents and addressed identified needs by providing information about available resources, offering direct assistance, and making referrals to community agencies. Implementation outcomes included fidelity, feasibility, acceptability, and appropriateness.

Results

Observations from clinical staff characterized fidelity to use of the SSNAC questionnaire, assessment template, and shared decision-making for follow-up on unmet social needs. Levels of agreement (5-point Likert scale; 1 = completely disagree; 5 = completely agree) rated by staff for key implementation outcomes were moderate to high for acceptability (mean = 4.7; range = 3–5), feasibility (mean = 4.2; range = 3–5), and appropriateness (mean = 4.6; range = 4-5). 49 SSNAC questionnaires were completed with a 91% response rate. Among participating parents, 37 (76%) reported ≥ 1 social need, including food/nutrition benefits (41%), housing (18%), and caregiver needs (29%). Staff responses included information provision (41%), direct assistance (30%), and agency referral (30%).

Conclusions

It was feasible for tertiary care center-based pediatric complex care programs to implement a standardized social needs assessment for CMC to identify and address parent-reported unmet social needs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s43058-021-00237-3.

A Mixed-Methods Feasibility Study of Integrated Pediatric Complex Care: Experiences of Parents With Care and the Value of Parent Engagement in Research

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.

Complexity of Documentation Needs for Children With Medical Complexity: Implications for Hospital Providers

OBJECTIVES

Care coordination is a core component of pediatric complex care programs (CCPs) supporting children with medical complexity (CMC) and their families. In this study, we aim to describe the purpose and characteristics of clinical care notes used within a pediatric CCP.

METHODS

We conducted observations of provider-family interactions during CCP clinic visits and 5 focus groups with members of the CCP. Focus groups were recorded and transcribed. Field observation notes and focus group transcripts were subjected to qualitative content analyses.

RESULTS

Four major themes help characterize clinical care notes: (1) Diversity of note types and functions: program staff author and use a number of unique note types shared across multiple stakeholders, including clinicians, families, and payers. (2) motivations for care note generation are different and explain how, why, and where they are created. (3) Program staff roles and configuration vary in relation to care note creation and use. (4) Sources of information for creating and updating notes are also diverse. Given the disparate information sources, integrating and maintaining up-to-date information for the child is challenging. To minimize information gaps, program staff devised unique but resource-intensive strategies, such as accompanying families during specialty clinic visits or visiting them inpatient.

CONCLUSIONS

CMC have complex documentation needs demonstrated by a variety of professional roles, care settings, and stakeholders involved in the generation and use of notes. Multiple opportunities exist to redesign and streamline the existing notes to support the cognitive work of clinicians providing care for CMC.

Variables Prevalent Among Early Unplanned Readmissions in Infants Following Congenital Heart Surgery

Medically complex children including infants undergoing cardiac surgery are at increased risk for hospital readmissions. Investigation of this population may reveal opportunities to optimize systems and coordination of care. A retrospective study of all infants undergoing cardiac surgery from 2015 through 2016 at a large tertiary institution who were readmitted within 1 year of discharge from cardiac surgical hospitalization was performed. Data specific to patient characteristics, surgical hospitalization, and readmission hospitalization are described. Unplanned readmissions within 1 year of hospital discharge were analyzed with Cox proportional hazard regression to identify factors associated with increased hazard for earlier unplanned readmission. Comparable to previous reports, 12% (78/658) of all surgical hospitalizations were associated with unplanned readmission within 30 days. Infectious etiology, followed by cardiac and gastrointestinal problems, was the most common reasons for unplanned 30-day readmission. Unplanned readmissions within 2 weeks of discharge were multifactorial and less commonly related to cardiac or surgical care. Primary nasogastric tube feeding at the time of discharge was the only significant risk factor for earlier unplanned readmission (p = 0.032) on multivariable analysis. Increased care coordination with particular attention to feeding and comorbidity management may be future targets to effectively mitigate readmissions and improve quality of care in this population.

Family Experiences with Care for Children with Inherited Metabolic Diseases in Canada: A Cross-Sectional Survey

Background and Objective

Children with inherited metabolic diseases often require complex and highly specialized care. Patient and family-centered care can improve health outcomes that are important to families. This study aimed to examine experiences of family caregivers (parents/guardians) of children diagnosed with inherited metabolic diseases with healthcare to inform strategies to improve those experiences.

Methods

A cross-sectional mailed survey was conducted of family caregivers recruited from an ongoing cohort study. Participants rated their healthcare experiences during their child’s visits to five types of healthcare settings common for inherited metabolic diseases: the metabolic clinic, the emergency department, hospital inpatient units, the blood laboratory, and the pharmacy. Participants provided narrative descriptions of any memorable negative or positive experiences.

Results

There were 248 respondents (response rate 49%). Caregivers were generally very or somewhat satisfied with the care provided at each care setting. Appropriate treatment, provider knowledge, provider communication, and care coordination were deemed essential aspects of satisfaction with care by the majority of participants across many settings. Memorable negative experiences were reported by 8–22% of participants, varying by setting. Among participants who reported memorable negative experiences, contributing factors included providers’ demeanor, lack of communication, lack of involvement of the family, and disregard of an emergency protocol letter provided by the family.

Conclusions

While caregivers’ satisfaction with care for children with inherited metabolic diseases was high, we identified gaps in family-centered care and factors contributing to negative experiences that are important to consider in the future development of strategies to improve pediatric care for inherited metabolic diseases.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00538-8.

[Current situation of children with medical complexity: An experience between primary and hospital care]

Objetivo

Analizar la valoración de la atención a los niños con patología crónica compleja (NPCC) en atención primaria (AP), desde el punto de vista de sus médicos y de sus familias.

Diseño

Estudio observacional, descriptivo y transversal.

Emplazamiento

Pediatría de AP y unidad de patología crónica compleja (UPCC) del Hospital Universitario La Paz (HULP).

Participantes

Pacientes y familiares de la UPCC y sus médicos de AP de la Comunidad de Madrid (CAM).

Intervenciones

Realización de encuestas validadas presenciales y online.

Mediciones principales

Grado de satisfacción en la formación, capacitación y manejo específico del NPCC según escalas tipo Likert.

Resultados

Se encuestaron 53 familias y 170 médicos de AP (96,5% pediatras). Los resultados de la encuesta a familiares revelan descoordinación entre niveles asistenciales (73,6%), escasa confianza en el primer nivel asistencial e impresión de poca capacidad de resolución de problemas por parte de pediatría de AP (50%).

Entre los médicos de AP destaca la poca formación para el seguimiento de los NPCC (96,5%), escasa experiencia en su manejo (93%) e insuficiente comunicación con el hospital (80,5%).

La falta de tiempo en las consultas es un problema común, percibido por pediatras y pacientes.

Conclusiones

La falta de coordinación entre AP y atención hospitalaria (AH) se detecta como un problema importante en la continuidad asistencial de NPCC. Son necesarias intervenciones que mejoren esta coordinación. La AP es cercana a la familia, pero precisa mejorar la formación y capacitación de los profesionales en problemas de salud y soporte tecnificado de NPCC, así como incrementar el tiempo necesario para su atención.

Children with medical complexity: A concept analysis

AIM

The aim of this paper is to conduct a concept analysis on the term, "children with medical complexity."

BACKGROUND

Children with medical complexity (CMC) describes pediatric patients with chronic, sustained acuity; however, there is a lack of consensus in the literature regarding its exact meaning, characteristics, and implications.

DESIGN

This analysis relied upon the framework described by Walker and Avant.

DATA SOURCE

The CINAHL, MEDLINE, and PubMed databases were queried from April 2020 to December 2020 with an initial search of the literature for the keyword, "children with medical complexity" and other associated terms, such as "pediatric medical complexity" and "nursing care of children with medical complexity."

REVIEW METHODS

This analysis will explore the concept of CMC and its significance, attributes, antecedents, and consequences.

RESULTS

This investigation revealed that CMC are a growing population of pediatric patients who have one or more complex chronic conditions that affect multiple body systems, experience functional limitations, require extensive care coordination from multiple providers, and are dependent upon life-sustaining medical technology.

CONCLUSIONS

The findings can serve as a foundation for future work advancing the understanding of the topic of CMC.

An implementation model for managing cloud-based longitudinal care plans for children with medical complexity

OBJECTIVE

We aimed to iteratively refine an implementation model for managing cloud-based longitudinal care plans (LCPs) for children with medical complexity (CMC).

MATERIALS AND METHODS

We conducted iterative 1-on-1 design sessions with CMC caregivers (ie, parents/legal guardians) and providers between August 2017 and March 2019. During audio-recorded sessions, we asked participants to walk through role-specific scenarios of how they would create, review, and edit an LCP using a cloud-based prototype, which we concurrently developed. Between sessions, we reviewed audio recordings to identify strategies that would mitigate barriers that participants reported relating to 4 processes for managing LCPs: (1) taking ownership, (2) sharing, (3) reviewing, and (4) editing. Analysis informed iterative implementation model revisions.

RESULTS

We conducted 30 design sessions, with 10 caregivers and 20 providers. Participants emphasized that cloud-based LCPs required a team of owners: the caregiver(s), a caregiver-designated clinician, and a care coordinator. Permission settings would need to include universal accessibility for emergency providers, team-level permission options, and some editing restrictions for caregivers. Notifications to review and edit the LCP should be sent to team members before and after clinic visits and after hospital encounters. Mitigating double documentation barriers would require alignment of data fields between the LCP and electronic health record to maximize interoperability.

DISCUSSION

These findings provide a model for how we may leverage emerging Health Insurance Portability and Accountability Act-compliant cloud computing technologies to support families and providers in comanaging health information for CMC.

CONCLUSIONS

Utilizing these management strategies when implementing cloud-based LCPs has the potential to improve team-based care across settings.

Healthcare Utilization of Complex Chronically Ill Children Managed by a Telehealth-Based Team

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.

Impact of telemedicine on health outcomes in children with medical complexity: an integrative review

Children with medical complexity (CMC) are a high priority population with chronic illnesses dependent on the use of health services, on technological systems to support their vital functions and characterized by multiple health needs. One of the main challenges linked to chronic conditions is finding solutions to monitor CMC at home, avoiding re-hospitalization and the onset of complications. Telemedicine enables to remotely follow up patients and families. An integrative review was performed to assess whether telemedicine improves health outcomes for CMC. Medline/PubMed, CINAHL, Cochrane Library, Web of Science, and Scopus were searched to identify studies describing the effect of using telemedicine systems on health outcomes for CMC. The PRISMA guidelines were used to select the papers. The methodological quality of the studies was evaluated through the Johanna Briggs Institute critical appraisal tools and the Cochrane Collaboration ROB 2.0. A total of 17 papers met the quality criteria and were included. Specialized telemedicine systems (tele-visits), telehealth, and tele-monitoring have been reported to reduce unplanned hospitalizations and visits, decrease total costs for healthcare services and families, and increase satisfaction for family members. No effect was found on the quality of life in children and their families.Conclusion: Available evidence supporting the use of telemedicine in CMC is favorable but limited. High-quality methodological studies including other unexplored health outcomes such as mental health, hospital readmissions, mortality, caregiver competences, and self-efficacy are needed to confirm the effectiveness of telemedicine systems in improving health outcomes for CMC. What is Known: • CMC are an extremely fragile patient population with frequent access to healthcare services compared with other chronic conditions. • There is conflicting evidence of the effectiveness of telemedicine clinical outcomes, healthcare utilization, and costs in pediatrics. What is New: • There is some evidence that for CMC, telemedicine reduces unplanned hospitalizations, healthcare service costs, and financial burden for families, while increasing caregivers' satisfaction with care. • Further research is needed to confirm the effectiveness of telemedicine systems in improving health for CMC.

Stakeholder perspectives: Communication, care coordination, and transitions in care for children with medical complexity

PURPOSE

The purpose of this study was to obtain feedback on communication, care coordination, and transitions in care for hospitalized children with medical complexity (CMC).

DESIGN AND METHODS

This descriptive, mixed-methods study used online surveys with forced-choice and open-ended questions to obtain stakeholder feedback. Stakeholders included parents, healthcare providers, and nurses. Participants over 18 years of age were recruited from a Midwest children's hospital inpatient unit dedicated to care of CMC. Quantitative data were analyzed using t-tests and one-way analysis of variance. Qualitative description was used to analyze responses to open-ended questions.

RESULTS

Parents' ratings of communication, care coordination, and transitions in care were generally high. Transitions from other facilities to the emergency department and unit received lower ratings. Providers and nurses gave high ratings to overall care, communication among providers and nurses on the patient unit, and experiences with discharge; however, between unit communication and unit-based coordination received lower ratings. Providers and nurses had higher ratings for discharge preparation than parents (p ≤ .001). Three themes were identified in responses to the open-ended questions: establishing balanced and collaborative relationships between the care team and families, taking a proactive approach to care coordination, and the importance of an inclusive, interdisciplinary, and centralized approach to care coordination and communication.

PRACTICE IMPLICATIONS

Collaboration among all stakeholders is needed to achieve coordinated care, inclusive communication, and transitions with positive outcomes during hospitalization. Parents identified a need for consistent communication from care teams, with the primary inpatient team taking a lead role. Including parents in care coordination and transitions in care is key, as they are the experts in their children's health and well-being.

Point-of-Care Complexity Screening Algorithm to Identify Children With Medical Complexity

OBJECTIVES

For pediatric complex care programs to target enhanced care coordination services to the highest-risk patients, it is critical to accurately identify children with medical complexity (CMC); however, no gold standard definition exists. The aim of this study is to describe a point-of-care screening algorithm to identify CMC with high health care use, a group that may benefit the most from improved care coordination.

METHODS

From July 1, 2015, to June 30, 2016 (fiscal year 2016 [FY16]), a medical complexity screening algorithm was implemented by a pediatric complex care program at a single tertiary care center for hospitalized patients at the time of admission. Using the screening algorithm, we categorized inpatients into 1 of 3 groups: CMC, children with special health care needs (CSHCN), or previously healthy (PH) children. Inpatient resource use for FY16 and FY17 encounters was extracted for children screened in FY16.

RESULTS

We categorized 2187 inpatients in FY16 into the 3 complexity groups (CMC = 77; CSHCN = 1437; PH children = 673). CMC had more complex chronic conditions (median = 6; interquartile range [IQR] 4-11) than CSHCN (median = 1; IQR 0-2) and PH children (median = 0; IQR 0-0). CMC had greater per-patient and per-encounter hospital use than CSHCN and PH children. CMC and children with ≥4 complex chronic conditions had comparable levels of resource use.

CONCLUSIONS

By implementation of a point-of-care screening algorithm, we identified CMC with high health care use. By using this algorithm, it was feasible to identify hospitalized CMC that could benefit from care coordination by a pediatric complex care program.

Social isolation and exclusion: the parents' experience of caring for children with rare neurodevelopmental disorders

Purpose: The experiences of parents caring for the complex care needs of children with rare neurodevelopmental disorders are not well understood. Parents struggle to meet their children's medical, behavioural, and social needs within and across health, social, and family systems. The purpose of this study was to explore the parents' experience of caring for medical and social care needs for children with rare neurodevelopmental disorders.Methods: Hermeneutic phenomenology was used for the data analysis. Fifteen parents participated in semi-structured interviews.Results: Interpretive analysis revealed four insights: (a) difference in children's behaviours and disease manifestations led to misunderstanding and vulnerability within social domains, (b) social taboo and stigma were experienced with rarity, (c) fragmented disconnected care from health and social systems impacted families, and (d) incomprehension from friends and family occurs when managing daily care.Conclusion: New interpretations and increased understanding of parents' experiences are required in supporting parents caring for children with complex needs. Understanding parents' experiences could reduce social isolation and exclusion, and mitigate appropriate and supportive practices and services within and across medical, social, and family systems.