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Albin JL, Mignucci AJ, Siler M, Dungan D, Neff C, Faris B, McCardell CS, Harlan TS. From Clinic to Kitchen to Electronic Health Record: The Background and Process of Building a Culinary Medicine eConsult Service. J Multidiscip Healthc 2024; 17:2777-2787. [PMID: 38863766 PMCID: PMC11166169 DOI: 10.2147/jmdh.s461377] [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: 03/08/2024] [Accepted: 05/27/2024] [Indexed: 06/13/2024] Open
Abstract
Diet plays a pivotal role in health outcomes, influencing various metabolic pathways and accounting for over 20% of risk-attributable disability adjusted life years (DALYs). However, the limited time during primary care visits often hinders comprehensive guidance on dietary and lifestyle modifications. This paper explores the integration of electronic consultations (eConsults) in Culinary Medicine (CM) as a solution to bridge this gap. CM specialists, with expertise in the intricate connections between food, metabolism, and health outcomes, offer tailored dietary recommendations through asynchronous communication within the electronic health record (EHR) system. The use of CM eConsults enhances physician-patient communication and fosters continuous medical education for requesting clinicians. The benefits extend directly to patients, providing access to evidence-based nutritional information to address comorbidities and improve overall health through patient empowerment. We present a comprehensive guide for CM specialist physicians to incorporate CM eConsults into their practices, covering the historical context of eConsults, their adaptation for CM, billing methods, and insights from the implementation at UT Southwestern Medical Center. This initiative delivers expanded access to patient education on dietary risks and promotes interprofessional collaboration to empower improved health.
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Affiliation(s)
- Jaclyn Lewis Albin
- Departments of Internal Medicine and Pediatrics, University of Texas at Southwestern, Dallas, Texas, USA
| | - Alexandra J Mignucci
- Department of Family Medicine, University of California San Diego, San Diego, CA, USA
| | - Milette Siler
- Moncrief Cancer Institute and the University of Texas Southwestern Medical Center, Fort Worth and Dallas, TX, USA
| | - David Dungan
- Departments of Internal Medicine and Pediatrics, Duly Health and Care, Lombard and Downers Grove, IL, USA
| | - Cary Neff
- Conscious Food Solutions, Inc, Oro Valley, AZ, USA
| | - Basma Faris
- Raquel and Jaime Gilinski Department of Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Timothy S Harlan
- Department of Medicine, George Washington University School of Medicine, Washington, DC, USA
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Sidra M, Sebastianski M, Ohinmaa A, Rahman S. Reported costs of children with medical complexity-A systematic review. J Child Health Care 2024; 28:377-401. [PMID: 35751147 DOI: 10.1177/13674935221109683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Examining reported costs for Children with Medical Complexity (CMCs) is essential because costing and resource utilization studies influence policy and operational decisions. Our objectives were to (1) examine how authors identified CMCs in administrative databases, (2) compare reported costs for the CMC population in different study settings, and (3) analyze author recommendations related to reported costs. We undertook a systematic search of the following databases: Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBase, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library with a focus on CMCs as a heterogeneous group. The most common method used n = 11 (41%) to identify the CMC population in administrative data was the Complex Chronic Conditions methodology. The majority of included studies reported on health care service costs n = 24 (89%). Only n = 3 (11%) of the studies included costs from the family perspective. Author recommendations included standardizing how costs are reported and including the family perspective when making care delivery or policy decisions. Health system administrators and policymakers must consider the limitations of reported costs when assessing local costing studies or comparing costs across jurisdictions.
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Affiliation(s)
- Michael Sidra
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Meghan Sebastianski
- Alberta Strategy for Patient-Oriented Research (SPOR) Knowledge Synthesis Platform, University of Alberta, Edmonton, AB, Canada
| | - Arto Ohinmaa
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Sholeh Rahman
- Alberta Strategy for Patient-Oriented Research (SPOR) Knowledge Synthesis Platform, University of Alberta, Edmonton, AB, Canada
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Oumarbaeva-Malone Y, Jurgens V, Rush M, Bloom M, Adusei-Baah C, Hall M, Shah N, Bhansali P, Parikh K. Care Models and Discharge Services for Children With Medical Complexity. Hosp Pediatr 2024; 14:102-107. [PMID: 38196385 DOI: 10.1542/hpeds.2023-007423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2023] [Indexed: 01/11/2024]
Abstract
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.
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Affiliation(s)
- Yuliya Oumarbaeva-Malone
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Valerie Jurgens
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Margaret Rush
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Miriam Bloom
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Charity Adusei-Baah
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | | | - Neha Shah
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Priti Bhansali
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
| | - Kavita Parikh
- Children's National Hospital, Washington DC
- The George Washington University School of Medicine and Health Sciences, Washington DC
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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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Huang J, Huang Z, Mei H, Rong L, Zhou Y, Guo J, Wan L, Xu Y, Tang S. Cost-effectiveness analysis of robot-assisted laparoscopic surgery for complex pediatric surgical conditions. Surg Endosc 2023; 37:8404-8420. [PMID: 37721590 DOI: 10.1007/s00464-023-10399-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 08/14/2023] [Indexed: 09/19/2023]
Abstract
BACKGROUND Robotics has been used safely and successfully in a variety of adult surgeries and is gradually gaining ground in pediatrics. While the benefits of robotic-assisted surgery in disease treatment are well recognized, its high cost has led to questions. To investigate whether robotic-assisted laparoscopic surgery (RALS) is cost-effective compared to conventional laparoscopic surgery (LS) in pediatric surgery, we attempted to construct a model to perform an analysis of these two surgical approaches using Python statistical analysis software. METHODS We selected four common complex pediatric surgical conditions (choledochal cyst, Hirschsprung's disease, vesicoureteral reflux, and congenital hydronephrosis) from three systems (pediatric hepatobiliary, gastroenterology, and urology). Models were constructed using Python statistical software to compare hospital costs and surgical outcomes for RALS and LS. In addition, we performed a preferred strategy analysis for both surgical modalities while assessing model uncertainty using one-way sensitivity analysis. RESULTS For the four diseases, the operative time decreased sequentially. The total inpatient costs of RALS were 10,816.72, 9145.44, 8414.29, 7973.58 dollars, respectively, yielding 1.789, 1.712, 1.749, 1.792 quality adjustment life years (QALYs) over two years post-operatively. The incremental cost of RALS relative to LS for each disease was 3523.44, 3200.20, 3049.79, 3043.66 dollars, respectively, with an incremental utility of 0.060, 0.054, 0.051, 0.050 QALYs. The incremental cost-effectiveness ratios (ICERs) for RALS for each of the four diseases were 58,724.01, 59,262.95, 59,799.79, 60,873.20 dollars/QALY, all less than 100,000 dollars/QALY. The cost of robot consumables was the main incremental cost of RALS and had the most significant impact on the model. CONCLUSION For the four pediatric surgical conditions described above, RALS has higher inpatient costs than LS, but it has better postoperative outcomes, and all four RALS treatments are cost-effective. Children with complex diseases and long operative times appear to benefit more from RALS.
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Affiliation(s)
- Jiangrui Huang
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Zhong Huang
- Department of Computer Science, University of Science and Technology of China, Hefei, China
| | - Hong Mei
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Liying Rong
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yun Zhou
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jialing Guo
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Li Wan
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yinhui Xu
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Shaotao Tang
- Department of Pediatric Surgery, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China.
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Roumeliotis N, Desforges J, French ME, Dupre-Roussel J, Fiest KM, Lau VI, Lacroix J, Carnevale FA. Patient and Family Experience With Discharge Directly Home From the Pediatric ICU. Hosp Pediatr 2023; 13:954-960. [PMID: 37667850 DOI: 10.1542/hpeds.2023-007332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
BACKGROUND Children are increasingly discharged directly from the PICU. Transitions have been recognized as a period of increased patient and caregiver stress and risk of adverse events. No study has evaluated patient and caregiver outcomes after direct discharge from the PICU. This study aimed to explore the family's experiences with discharge directly home (DDH) from the PICU. METHODS This exploratory mixed-methods study was conducted in the PICU of the Institution is Sainte-Justine Hospital from February to July 2021. We included families of children expected to be DDH within 12 hours. Semistructured interviews were conducted at discharge, followed by telephone interviews 7 and 28 days post-PICU discharge. We measured comfort on a 5-point Likert scale and screened for anxiety using the Generalized Anxiety Disorder-7 tool. RESULTS Families of 25 patients were interviewed. Thematic analysis of the interviews revealed several themes, such as feeling stress and anxiety, feeling confident, anticipating home care, and needing support. These findings complemented the quantitative findings; the median comfort score was 4 (comfortable) (interquartile range 4-5) and 8 (interquartile range 4-12) for the Generalized Anxiety Disorder-7 on the day of discharge, with 16 reporting clinically significant anxiety. In the 28-day study period, 2 patients were readmitted and 6 had visited the emergency department. CONCLUSIONS Despite feelings of anxiety, many families felt comfortable with DDH from the PICU. Increasing our understanding of the patient and family experiences of discharge from the PICU will help to better support these patients and their families during transition.
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Affiliation(s)
| | | | | | | | - Kirsten M Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Vincent I Lau
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Alberta, Canada
| | - Jacques Lacroix
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Franco A Carnevale
- Ingram School of Nursing, McGill University, Montreal, Quebec, Canada
- Pediatric ICU, Montreal Children's Hospital, Montreal, Quebec, Canada
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Noritz G, Davidson L, Steingass K. Providing a Primary Care Medical Home for Children and Youth With Cerebral Palsy. Pediatrics 2022; 150:e2022060055. [PMID: 36404756 DOI: 10.1542/peds.2022-060055] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Cerebral palsy (CP) is the most common motor disorder of childhood, with prevalence estimates ranging from 1.5 to 4 in 1000 live births. This clinical report seeks to provide primary care physicians with guidance to detect children with CP; collaborate with specialists in treating the patient; manage associated medical, developmental, and behavioral problems; and provide general medical care to their patients with CP.
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Affiliation(s)
- Garey Noritz
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
| | - Lynn Davidson
- The Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York
| | - Katherine Steingass
- Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio; and
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Ettinger NA, Hill VL, Russ CM, Rakoczy KJ, Fallat ME, Wright TN, Choong K, Agus MSD, Hsu B, Mack E, Day S, Lowrie L, Siegel L, Srinivasan V, Gadepalli S, Hirshberg EL, Kissoon N, October T, Tamburro RF, Rotta A, Tellez S, Rauch DA, Ernst K, Vinocur C, Lam VT, Romito B, Hanson N, Gigli KH, Mauro M, Leonard MS, Alexander SN, Davidoff A, Besner GE, Browne M, Downard CD, Gow KW, Islam S, Saunders Walsh D, Williams RF, Thorne V. Guidance for Structuring a Pediatric Intermediate Care Unit. Pediatrics 2022; 149:186777. [PMID: 35490284 DOI: 10.1542/peds.2022-057009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Nicholas A Ettinger
- Section of Critical Care, Department of Pediatrics, Baylor College of Medicine/Texas Children's Hospital, Houston, Texas
| | - Vanessa L Hill
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine/The Children's Hospital of San Antonio, San Antonio, Texas
| | - Christiana M Russ
- Intermediate Care Program.,Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Katherine J Rakoczy
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Tuft's Children's Hospital, Boston, Massachusetts
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk Jr Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
| | - Karen Choong
- Division of Critical Care, Department of Pediatrics, McMaster University, Ontario, Canada
| | - Michael S D Agus
- Division of Medical Critical Care, Boston Children's Hospital, Boston, Massachusetts
| | - Benson Hsu
- Division of Critical Care, Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
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Vandermeer RJ, Kain VJ, Hoehn KS. Palliative Care Across the Continuum of Childhood. Pediatr Ann 2022; 51:e40-e46. [PMID: 35020515 DOI: 10.3928/19382359-20211214-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Palliative care should be integrated along the continuum for all children living with life-limiting illness. Many misconceptions about palliative care exist, including the misunderstanding that palliative and curative care are mutually exclusive. Many associate palliative care with hospice and do not recognize that palliative care is available and beneficial before end of life. Palliative care should be initiated at the time a family receives a life-limiting diagnosis and should continue throughout the child's life. Children may have a better quality of life and even longer life span when palliative care has an earlier initiation. In this article, we discuss these common misconceptions and describe how children and families benefit from palliative care when it is integrated along the illness continuum. In addition, we discuss how pediatricians can incorporate these principles into their practice to support their families. [Pediatr Ann. 2022;51(1):e40-e46.].
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deJong NA, Wofford M, Song PH, Kappelman MD. Association of Care Coordination Experience and Health Services Use with Main Provider Type for Children with Inflammatory Bowel Disease. J Pediatr 2021; 234:142-148.e1. [PMID: 33798510 PMCID: PMC8238824 DOI: 10.1016/j.jpeds.2021.03.013] [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] [Received: 10/21/2020] [Revised: 01/29/2021] [Accepted: 03/10/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To describe care coordination experience for families of children with inflammatory bowel disease (IBD) and compare use of health services between families who identified a primary care physician (PCP) vs a gastroenterologist as a child's main provider. STUDY DESIGN This is a cross-sectional survey of care coordination experiences and health services use for children 6-19 years old receiving care in the IBD program at a children's hospital during 2018. English-speaking parents completed the Family Experiences with Coordination of Care Survey about their child's main provider and reported past-year health services. Bivariate testing and multivariate logistic regression explored differences in care coordination experience and health services by main provider, adjusted for demographic and clinical variables. RESULTS A total of 113 of 270 (42%) invited patients participated. Among 101 patients with complete data, 41% identified a PCP main provider. Performance on 5 of 16 Family Experiences with Coordination of Care indicators was higher for patients reporting a gastroenterologist vs a PCP main provider. However, having a PCP vs gastroenterologist main provider was associated with greater use of any past-year primary care services (adjusted proportion 94% vs 75%; P = .01) and of mental health services when needed (95% vs 60%; P < .01). Need for IBD-related hospitalization and emergency department visits did not differ between groups. CONCLUSIONS Children with IBD may experience trade-offs in care coordination quality and important, non-disease-focused health services based on whom parents perceive as the main provider. Efforts to enhance cross-team coordination among families and primary and specialty care teams are needed to improve overall care quality.
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Affiliation(s)
- Neal A. deJong
- Division of General Pediatrics and Adolescent Medicine, UNC School of Medicine
| | - Marie Wofford
- Department of Emergency Medicine, Carolinas Medical Center
| | - Paula H. Song
- Department of Health Administration, VCU College of Health Professions
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Malhotra NA, Nevar A, Yearby R, Kleinman LC, Ronis S. Medicaid's EPSDT Benefit: An Opportunity to Improve Pediatric Screening for Social Determinants of Health. Med Care Res Rev 2021; 78:87-102. [PMID: 31524053 PMCID: PMC7071991 DOI: 10.1177/1077558719874211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit is a key component of Medicaid policy intended to define an essential set of services provided to patients younger than age 21. Given increasing attention to social determinants of health in pediatric health care, this qualitative review examines the extent to which EPSDT might be used to implement structured screening to identify environmental and social factors affecting children's health. Themes derived from semistructured interviews conducted in 2017 were triangulated with a review of the recent literature to describe how states currently consider the EPSDT benefit with respect to social determinants of health screening. Our findings suggest that, with sufficient stakeholder advocacy given the evidence supporting social determinants of health screening as "medically necessary," EPSDT benefits could be considered as a funding source to incentivize the incorporation of social determinants of health screening into the basic package of well-child care.
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Affiliation(s)
| | - Ann Nevar
- Clinical and Translational Science Collaborative, Case Western Reserve University, Cleveland, Ohio
| | | | - Lawrence C. Kleinman
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | - Sarah Ronis
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- UH Rainbow Center for Child Health and Policy, UH Rainbow Babies & Children’s Hospital, Cleveland, Ohio
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Boyden JY, Ersek M, Deatrick JA, Widger K, LaRagione G, Lord B, Feudtner C. What Do Parents Value Regarding Pediatric Palliative and Hospice Care in the Home Setting? J Pain Symptom Manage 2021; 61:12-23. [PMID: 32745574 PMCID: PMC9747513 DOI: 10.1016/j.jpainsymman.2020.07.024] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/22/2020] [Accepted: 07/27/2020] [Indexed: 12/16/2022]
Abstract
CONTEXT Children with life-shortening serious illnesses and medically-complex care needs are often cared for by their families at home. Little, however, is known about what aspects of pediatric palliative and hospice care in the home setting (PPHC@Home) families value the most. OBJECTIVES To explore how parents rate and prioritize domains of PPHC@Home as the first phase of a larger study that developed a parent-reported measure of experiences with PPHC@Home. METHODS Twenty domains of high-value PPHC@Home, derived from the National Consensus Project's Guidelines for Quality Palliative Care, the literature, and a stakeholder panel, were evaluated. Using a discrete choice experiment, parents provided their ratings of the most and least valued PPHC@Home domains. We also explored potential differences in how subgroups of parents rated the domains. RESULTS Forty-seven parents participated. Overall, highest-rated domains included Physical aspects of care: Symptom management, Psychological/emotional aspects of care for the child, and Care coordination. Lowest-rated domains included Spiritual and religious aspects of care and Cultural aspects of care. In exploratory analyses, parents who had other children rated the Psychological/emotional aspects of care for the sibling(s) domain significantly higher than parents who did not have other children (P = 0.02). Furthermore, bereaved parents rated the Caregiversupportat the end of life domain significantly higher than parents who were currently caring for their child (P = 0.04). No other significant differences in domain ratings were observed. CONCLUSION Knowing what parents value most about PPHC@Home provides the foundation for further exploration and conversation about priority areas for resource allocation and care improvement efforts.
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Affiliation(s)
- Jackelyn Y Boyden
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Mary Ersek
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Janet A Deatrick
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kimberley Widger
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada; Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gwenn LaRagione
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Blyth Lord
- Courageous Parents Network, Newton, MA, USA
| | - Chris Feudtner
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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13
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Maypole J, Gavin T, de Banate MA, Sadof M. Lessons Learned, Best Practices: Care Coordination for Children with Medical Complexity. Pediatr Ann 2020; 49:e457-e466. [PMID: 33170293 DOI: 10.3928/19382359-20201018-01] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Although care coordination has long been established in the health care system in the United States, too often it may compete or work at cross purposes with care teams serving patients and families. Care coordination is a team sport that requires strong clinician-family partnerships as well as adequate time and resources to be done effectively. We incorporate the latest literature to offer clarity for identifying, coordinating, and funding care for children with medical complexity (CMC), the most medically fragile, high-cost subpopulation of children and youth with special health care needs. Algorithms for identifying CMC exist. Calculation of the cost of care for CMC is confounded by cost shifting to families and the variable course of illness and aging in this heterogeneous population. Multiple studies of different sizes have reported similar care coordination team structure, staffing ratios, and cost ranges. We describe models for funding this work and how they can be tailored to individual practice environments. [Pediatr Ann. 2020;49(11):e457-e466.].
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Abebe E, Scanlon MC, Lee KJ, Chui MA. What do family caregivers do when managing medications for their children with medical complexity? APPLIED ERGONOMICS 2020; 87:103108. [PMID: 32501256 DOI: 10.1016/j.apergo.2020.103108] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 01/13/2020] [Accepted: 04/01/2020] [Indexed: 06/11/2023]
Abstract
Using a work domain analysis and complementary thematic analysis, this paper aims to describe medication management work, its constraints, and complexities from the perspectives of family caregivers of children with medical complexity-a medically fragile segment of the pediatric population often dependent on multiple and complex medication regimens for survival and optimal functioning. Analyses were informed by data generated through observations of 12 care coordination clinic visits within a pediatric complex care program, semi-structured interviews of 11 family caregivers, and reviews of program documents. Our results show that family caregivers: (1) formulate medication management goals, identify values and criteria to judge goals but these may not necessarily be acknowledged and explicitly supported by system resources and healthcare professionals (2) are engaged in a range of complex medication management tasks that are both physically and emotionally demanding without the support of well-designed tools and resources to enhance their work.
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Affiliation(s)
- Ephrem Abebe
- Purdue University, Department of Pharmacy Practice, Fifth Third Bank Building, 640 Eskenazi Avenue, Indianapolis, IN, 46202, United States.
| | | | - K Jane Lee
- Medical College of Wisconsin, United States
| | - Michelle A Chui
- University of Wisconsin - Madison, School of Pharmacy, Madison, United States
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15
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Garrett N, Bikah Bi Nguema Engoang JA, Rubin S, Vickery KD, Winkelman TNA. Health system resource use among populations with complex social and behavioral needs in an urban, safety-net health system. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2020; 8:100448. [PMID: 32919587 DOI: 10.1016/j.hjdsi.2020.100448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Costs incurred by health systems when caring for populations with social or behavioral complexity are poorly understood. We compared the frequency and costs of unreimbursed care among individuals with complexity factors (homelessness, a history of county jail incarceration, and/or substance use disorder or mental illness [SUD/MI]). METHODS We conducted a cross-sectional analysis using electronic health record data for adults aged 18 and older between January 1, 2016 and December 31, 2017 from a Midwestern safety-net health system. Zero-inflated negative binomial regression models were used to assess risk-adjusted associations between complexity factors and care coordination encounters, missed appointments, and excess inpatient days. RESULTS Our sample included 154,719 unique patients; 6.8% were identified as homeless, 7.8% had a history of county jail incarceration, and 20.6% had SUD/MI. Individuals with complexity factors were more likely to be African-American, Native American, or covered by Medicaid. In adjusted models, homelessness and SUD/MI were significantly associated with care coordination encounters (RR 1.8 [95% CI,1.7-2.0]; RR 1.9 [95% CI,1.8-2.0]), missed appointments (RR 1.5 [95% CI,1.4-1.6]; RR 1.7 [95% CI,1.7-1.8]), and excess inpatient days (RR 1.5 [95% CI,1.3-1.8]; RR 2.8 [95% CI,2.5-3.1]). County jail incarceration was associated with a significant increase in missed appointments. In 2017, SUD/MI accounted for 81.8% ($7,773,000/$9,502,000) of excess costs among those with social or behavioral complexity. CONCLUSIONS Social and behavioral complexity are independently associated with high levels of unreimbursed health system resource use. IMPLICATIONS Future payment models should account for the health system resources required to care for populations with complex social and behavioral needs. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Nancy Garrett
- Analytics Center of Excellence, Hennepin Healthcare, Minneapolis, MN, USA; Aetna, Hartford, CT, USA
| | | | - Stephen Rubin
- Analytics Center of Excellence, Hennepin Healthcare, Minneapolis, MN, USA
| | - Katherine Diaz Vickery
- Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA; Health, Homelessness, And Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Tyler N A Winkelman
- Division of General Internal Medicine, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, USA; Health, Homelessness, And Criminal Justice Lab, Hennepin Healthcare Research Institute, Minneapolis, MN, USA.
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16
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Quini E, Kaushik R. Is Managed Care Better Care? The Effects of Medicaid Managed Care on Children With Medical Complexity. Hosp Pediatr 2020; 10:709-711. [PMID: 32669284 DOI: 10.1542/hpeds.2020-0046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Emily Quini
- The Children's Hospital of San Antonio, San Antonio, Texas; and Department of General Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Ruchi Kaushik
- The Children's Hospital of San Antonio, San Antonio, Texas; and Department of General Pediatrics, Baylor College of Medicine, Houston, Texas
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Murphy NA, Alvey J, Valentine KJ, Mann K, Wilkes J, Clark EB. Children With Medical Complexity: The 10-Year Experience of a Single Center. Hosp Pediatr 2020; 10:702-708. [PMID: 32699000 DOI: 10.1542/hpeds.2020-0085] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Children with medical complexity (CMC) have chronic, multisystem health conditions, substantial health care needs, major functional limitations, and high resource use. They represent <1% of US children yet account for more than one-third of total pediatric health care costs. Health care systems designed for typical children do not meet the unique needs of CMC. In this special article, we describe the experience of our Comprehensive Care Program for CMC in a pediatric tertiary care center, from its launch in 2007 to its present model. We review the literature, describe our collective lessons learned, and offer suggestions for future directions.
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Affiliation(s)
- Nancy A Murphy
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah;
| | - Justin Alvey
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Karen J Valentine
- Intermountain Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah; and.,Healthcare Delivery Institute, Intermountain Healthcare, Murray, Utah
| | - Kilby Mann
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jacob Wilkes
- Intermountain Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah; and
| | - Edward B Clark
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
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18
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Johnston EE, Martinez I, Currie E, Brock KE, Wolfe J. Hospital or Home? Where Should Children Die and How Do We Make That a Reality? J Pain Symptom Manage 2020; 60:106-115. [PMID: 31887402 DOI: 10.1016/j.jpainsymman.2019.12.370] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 01/31/2023]
Abstract
CONTEXT Most of the 20,000 U.S. children dying of serious illnesses annually die in the hospital. It is unknown if this hospital death predominance reflects family wishes or systemic issues such as lack of hospice access. Hence, we need to better understand location of death preferences for children and their families. OBJECTIVE To better understand location of death preferences in North America, we reviewed the literature to examine the evidence for and against home death in seriously ill children (0-18 years). METHODS We searched English articles in PubMed, PsycINFO, and Embase published during 2000-2018 for articles related to parental, child/adolescent, and provider preference for death location and articles that correlated death location with bereavement or quality of life outcomes. RESULTS The search results (n = 877 articles and n = 58 abstracts of interest) were reviewed, and 34 relevant articles were identified. Parent, child, and provider preferences, bereavement outcomes, and associated factors all point to some preference for home death. These findings should be interpreted with several caveats: 1) many studies are small and prone to selection bias, 2) not all families prefer home death and some that do are not able to achieve home death due to inadequate home support, 3) studies of bereavement outcomes are lacking. CONCLUSION Adequate resources are needed to ensure children can die in their chosen location-be that home, hospital, or free-standing hospice. This review highlights research areas needed to better understand death location preference and programs and policies that will support home death for those that desire it.
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Affiliation(s)
- Emily E Johnston
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA; Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Isaac Martinez
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Erin Currie
- School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Katharine E Brock
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA; Aflac Cancer & Blood Disorders Center, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Joanne Wolfe
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA; Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Leary JC, Krcmar R, Yoon GH, Freund KM, LeClair AM. Parent Perspectives During Hospital Readmissions for Children With Medical Complexity: A Qualitative Study. Hosp Pediatr 2020; 10:222-229. [PMID: 32029432 PMCID: PMC7041550 DOI: 10.1542/hpeds.2019-0185] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Children with medical complexity (CMC) have high readmission rates, but relatively little is known from the parent perspective regarding care experiences surrounding and factors contributing to readmissions. We aimed to elicit parent perspectives on circumstances surrounding 30-day readmissions for CMC. METHODS We conducted 20 semistructured interviews with parents of CMC experiencing an unplanned 30-day readmission at 1 academic medical center between December 2016 and January 2018, asking about topics such as previous discharge experiences, medical services and resources, and home environment and social support. Interviews were recorded, professionally transcribed, and analyzed thematically by using a modified grounded theory approach. RESULTS Children ranged in age from 0 to 15 years, with neurologic complex chronic conditions being predominant (35%). Although the majority of parents did not identify any factors that they perceived to have contributed to readmission, themes emerged regarding challenges associated with chronicity of care and transitions of care that might influence readmissions, including frequency of hospital use, symptom confusion, lack of inpatient continuity, resources needed but not received, and difficulty filling prescriptions. CONCLUSIONS Parents identified multiple challenges associated with chronicity of medical management and transitions of care for CMC. Future interventions aiming to improve continuity and communication between admissions, ensure that home services are provided when applicable and prescriptions are filled, and provide comprehensive support for families in both the short- and long-term may help improve patient and family experiences while potentially decreasing readmissions.
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Affiliation(s)
- Jana C Leary
- Department of Pediatrics, Floating Hospital for Children,
| | - Rachel Krcmar
- School of Medicine, Tufts University, Boston, Massachusetts; and
| | - Grace H Yoon
- Department of Health Law, Policy, and Management, School of Public Health, Boston University, Boston, Massachusetts
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21
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D'Aprano A, Gibb S, Riess S, Cooper M, Mountford N, Meehan E. Important components of a programme for children with medical complexity: An Australian perspective. Child Care Health Dev 2020; 46:90-103. [PMID: 31782538 DOI: 10.1111/cch.12721] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Children with medical complexity (CMC) have high care needs, often unmet by traditional healthcare models. In response to this need, the Complex Care Service (CCS) at The Royal Children's Hospital (RCH), Melbourne was created. Although preliminary parent satisfaction data were available, we lacked knowledge of how the various components of the expanded service were valued and contributed to overall caregiver satisfaction. AIM The aims of this study were to (a) determine what caregivers value most about the CCS and (b) explore caregiver perceptions of care. METHODS All caregivers of children enrolled in the RCH CCS in April 2017 were invited to participate. A purposefully designed survey explored caregiver perceptions of care, including patient quality of care; the extent to which the CCS components added value and satisfaction; and frequency of contact. Participants were also invited to answer open-ended questions and provide general comments. RESULTS Responses were received from 53 families (51%). We found that 24-hr phone advice, coordination of appointments, a key contact, and access to timely information were the most important components of the service. More than 90% of caregivers indicated that they were satisfied with care and that the CCS improved their child's quality of care. Coordination, communication, family-centred care, quality care, and access were emergent themes within comments. CONCLUSION This study provides important information regarding the design and operation of services for CMC throughout Australia and further afield. Our findings highlight the importance of the key contact and family-centred care. This has implications for practice, as maintaining service quality, as the CCS expands and is implemented more widely, is a major sustainability challenge. It is crucial that we have a detailed understanding of what elements are required to support effective care coordination, to achieve successful implementation on a larger scale.
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Affiliation(s)
- Anita D'Aprano
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Population Health Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Susie Gibb
- Department of General Medicine, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Infection and Immunity Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Suzi Riess
- Population Health Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia
| | - Monica Cooper
- Department of Neurodevelopment & Disability, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia.,Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Nicki Mountford
- Quality and Improvement, The Royal Children's Hospital, Melbourne, Melbourne, Victoria, Australia
| | - Elaine Meehan
- Clinical Sciences Theme, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
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Abstract
PURPOSE OF REVIEW We review the literature to help the reader better understand the latest thinking on how best to identify, coordinate and fund care for children with medical complexity, a medically fragile high-cost subpopulation of children and youth with special healthcare needs. RECENT FINDINGS Proprietary and public algorithms have been developed to identify children with medical complexity. Research on families and healthcare providers of children with medical complexity have identified essential components of effective care coordination. Calculation of the cost of care for this population is confounded by cost shifting to families and the variable course of illness in this heterogeneous high-cost population. Care coordination is a team sport that requires strong family partnerships, adequate time and resources to be done effectively. Multiple studies of different sizes have reported similar care coordination team structure, staffing ratios and cost ranges. Multiple options for funding this work now exist and can be tailored to individual environments. SUMMARY Effective care coordination can positively impact the care of children with medical complexity. Recent work resulting in a better understanding of the needs of families and providers will guide the development of new technologies and measures.
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23
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Coller RJ, Ehlenbach ML. Making Time to Coordinate Care for Children With Medical Complexity. Pediatrics 2019; 143:peds.2018-2958. [PMID: 30584058 DOI: 10.1542/peds.2018-2958] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/22/2018] [Indexed: 11/24/2022] Open
Affiliation(s)
- Ryan J Coller
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
| | - Mary L Ehlenbach
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, Wisconsin
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