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Xu R, Hayes LC, Cai PY, Meers A, Tulley K, Antonelli RC, Estrada CR. Characterizing psychosocial services in a pediatric urology practice. J Pediatr Urol 2024; 20:242.e1-242.e8. [PMID: 38030431 PMCID: PMC11032223 DOI: 10.1016/j.jpurol.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 08/29/2023] [Accepted: 11/10/2023] [Indexed: 12/01/2023]
Abstract
INTRODUCTION Psychosocial needs, which encompass behavioral health and social determinants of health (SDOH), are important mediators of the patient experience and health outcomes. However, many practices have limited experience with systematically assessing the non-billable psychosocial services provided to patients and families. OBJECTIVE To characterize the non-billable activities of three psychosocial providers in a pediatric urology practice at a freestanding children's hospital. STUDY DESIGN Following Institutional Review Board approval, an adapted version of the Care Coordination Measurement Tool (CCMT) was used to collect data prospectively on non-billable activities performed by a psychologist, social worker (SW), and certified child life specialist (CCLS) in a pediatric urology department. Variables included activity type, time spent per activity, and outcomes affected. Demographic data included age, sex, race, state, zip code, insurance type, and language. RESULTS From April to October 2022, 3096 activities were performed in support of psychosocial needs over 947 encounters for 527 patients. The median patient age was 9.2 years (IQR 4.8-12.4); 48.4 % were male. The psychosocial providers most commonly identified care coordination needs related to delivery of urologic care (73.4 %), mental/behavioral/developmental health (29.1 %), and referral and appointment management (19.9 %). The largest proportion of time was spent on providing direct psychosocial support (45.9 %), consisting of psychosocial assessments, education, and other behavioral health interventions. A large proportion of time was also spent on care coordination activities, namely logistics and navigation support (35.9 %). Relative time allocation across activities varied by provider type (p < 0.001); care coordination constituted 64.2 % of non-billable activities for the psychologist, 57.8 % for the SW, and 12.3 % for the CCLS. Activities were associated with treatment plan modification in 37.7 % (n = 357), outpatient coordination in 22.5 % (n = 213), and treatment plan adherence in 19.0 % (n = 180) of encounters. DISCUSSION This study enhances our understanding of psychosocial needs of patients in a pediatric urology practice by assessing non-billable psychosocial services not otherwise captured in the clinical workflow. In addition to direct psychosocial support, care coordination activities constitute a large proportion of such services. These data provide valuable insight into the range of activities necessary for the provision of specialty pediatric medical care. CONCLUSION Psychosocial providers in a pediatric urology practice perform many non-billable care coordination and psychosocial support activities. Characterizing these activities is important for beginning to understand patients' psychosocial needs and informing resource deployment.
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Affiliation(s)
- Rena Xu
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Surgery, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Lillian C Hayes
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Peter Y Cai
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Surgery, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
| | - Amanda Meers
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Social Work, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Kelsey Tulley
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Child Life Services, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Richard C Antonelli
- Department of Pediatrics, Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
| | - Carlos R Estrada
- Department of Urology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Surgery, Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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Ming DY, Wong W, Jones KA, Antonelli RC, Gujral N, Gonzales S, Rogers U, Ratliff W, Shah N, King HA. Feasibility of Implementation of a Mobile Digital Personal Health Record to Coordinate Care for Children and Youth With Special Health Care Needs in Primary Care: Protocol for a Mixed Methods Study. JMIR Res Protoc 2023; 12:e46847. [PMID: 37728977 PMCID: PMC10551780 DOI: 10.2196/46847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Electronic health record (EHR)-integrated digital personal health records (PHRs) via Fast Healthcare Interoperability Resources (FHIR) are promising digital health tools to support care coordination (CC) for children and youth with special health care needs but remain widely unadopted; as their adoption grows, mixed methods and implementation research could guide real-world implementation and evaluation. OBJECTIVE This study (1) evaluates the feasibility of an FHIR-enabled digital PHR app for CC for children and youth with special health care needs, (2) characterizes determinants of implementation, and (3) explores associations between adoption and patient- or family-reported outcomes. METHODS This nonrandomized, single-arm, prospective feasibility trial will test an FHIR-enabled digital PHR app's use among families of children and youth with special health care needs in primary care settings. Key app features are FHIR-enabled access to structured data from the child's medical record, families' abilities to longitudinally track patient- or family-centered care goals, and sharing progress toward care goals with the child's primary care provider via a clinician dashboard. We shall enroll 40 parents or caregivers of children and youth with special health care needs to use the app for 6 months. Inclusion criteria for children and youth with special health care needs are age 0-16 years; primary care at a participating site; complex needs benefiting from CC; high hospitalization risk in the next 6 months; English speaking; having requisite technology at home (internet access, Apple iOS mobile device); and an active web-based EHR patient portal account to which a parent or caregiver has full proxy access. Digital prescriptions will be used to disseminate study recruitment materials directly to eligible participants via their existing EHR patient portal accounts. We will apply an intervention mixed methods design to link quantitative and qualitative (semistructured interviews and family engagement panels with parents of children and youth with special health care needs) data and characterize implementation determinants. Two CC frameworks (Pediatric Care Coordination Framework; Patient-Centered Medical Home) and 2 evaluation frameworks (Consolidated Framework for Implementation Research; Technology Acceptance Model) provide theoretical foundations for this study. RESULTS Participant recruitment began in fall 2022, before which we identified >300 potentially eligible patients in EHR data. A family engagement panel in fall 2021 generated formative feedback from family partners. Integrated analysis of pretrial quantitative and qualitative data informed family-centered enhancements to study procedures. CONCLUSIONS Our findings will inform how to integrate an FHIR-enabled digital PHR app for children and youth with special health care needs into clinical care. Mixed methods and implementation research will help strengthen implementation in diverse clinical settings. The study is positioned to advance knowledge of how to use digital health innovations for improving care and outcomes for children and youth with special health care needs and their families. TRIAL REGISTRATION ClinicalTrials.gov NCT05513235; https://clinicaltrials.gov/study/NCT05513235. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/46847.
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Affiliation(s)
- David Y Ming
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Willis Wong
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
| | - Kelley A Jones
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Richard C Antonelli
- Department of Pediatrics, Boston Children's Hospital, Harvard School of Medicine, Boston, MA, United States
| | - Nitin Gujral
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Sarah Gonzales
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
| | - Ursula Rogers
- AI Health, Duke University School of Medicine, Durham, NC, United States
| | - William Ratliff
- Duke Institute for Health Innovation, Duke University School of Medicine, Durham, NC, United States
| | - Nirmish Shah
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, United States
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
| | - Heather A King
- Department of Medicine, Duke University School of Medicine, Durham, NC, United States
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, United States
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veteran Affairs Health Care System, Durham, NC, United States
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Shapiro HFJ, Sant J, Minster A, Antonelli RC. Development and Evaluation of an Integrated Outpatient Infusion Care Model for the Treatment of Pediatric Headache. Pediatr Neurol 2022; 127:41-47. [PMID: 34959159 DOI: 10.1016/j.pediatrneurol.2021.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 11/10/2021] [Accepted: 11/28/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Care for pediatric patients with headache often occurs in high-cost settings such as emergency departments (EDs) and inpatient settings. Outpatient infusion centers have the potential to reduce care costs for pediatric headache management. METHODS In this quality improvement study, we describe our experience in creating the capacity to support an integrated outpatient pediatric headache infusion care model through an infusion center. We compare costs of receiving headache treatment in this model with those in the emergency and inpatient settings. Because dihydroergotamine (DHE) is a costly infusion, encounters at which DHE was administered were analyzed separately. We track the number of ED visits and inpatient admissions for headache using run charts. As a balancing measure, we compare treatment efficacy between the infusion care model and the inpatient setting. RESULTS The mean percentage increase in cost of receiving headache treatment in the inpatient setting with DHE was 61% (confidence interval [CI]: 30-99%), and that without DHE was 582% (CI: 299-1068%) compared with receiving equivalent treatments in the infusion center. The mean percentage increase in cost of receiving headache treatment in the ED was 30% (CI: -15 to 100%) compared with equivalent treatment in the infusion center. After the intervention, ED visits and inpatient admissions for headache decreased. The mean change in head pain was similar across care settings. CONCLUSIONS Our findings demonstrate that developing an integrated ambulatory care model with infusion capacity for refractory pediatric headache is feasible, and our early outcomes suggest this may have a favorable impact on the overall value of care for this population.
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Affiliation(s)
- Hannah F J Shapiro
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts.
| | - Jenifer Sant
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Anna Minster
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Antonelli RC, Bodamer O. Caring for Caregivers: Implications for Providing Authentic Family-Centered Care. Pediatrics 2021; 147:peds.2020-048249. [PMID: 33811180 DOI: 10.1542/peds.2020-048249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Olaf Bodamer
- Genetics and Genomics, Department of Pediatrics, Harvard Medical School, Harvard University and Boston Children's Hospital, Boston, Massachusetts
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Affiliation(s)
- Jeffrey S Schiff
- Minnesota Department of Human Services, St. Paul, Minnesota (Schiff); Integrated Care Program, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston (Antonelli)
| | - Richard C Antonelli
- Minnesota Department of Human Services, St. Paul, Minnesota (Schiff); Integrated Care Program, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston (Antonelli)
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Vaz LE, Farnstrom CL, Felder KK, Guzman-Cottrill J, Rosenberg H, Antonelli RC. Utilizing a Modified Care Coordination Measurement Tool to Capture Value for a Pediatric Outpatient Parenteral and Prolonged Oral Antibiotic Therapy Program. J Pediatric Infect Dis Soc 2018; 7:136-142. [PMID: 28419343 PMCID: PMC5954303 DOI: 10.1093/jpids/pix023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Accepted: 04/08/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND Outpatient parenteral or prolonged oral antibiotic therapy (OPAT) programs reduce inpatient healthcare costs by shifting care to outpatient settings. Care coordination (CC) is a necessary component to successfully transition patients. Our objective was to assess outcomes of provider time spent on nonreimbursable CC activities in a pediatric OPAT program. METHODS We used a qualitative feasibility pilot design and modified the Care Coordination Measurement Tool. We captured nonreimbursable CC activity and associated outcome(s) among pediatric patients enrolled in OPAT from March 1 to April 30, 2015 (44 work days) at Doernbecher Children's Hospital. We generated summary statistics for this institutional review board-waived QI project. RESULTS There were 154 nonreimbursable CC encounters conducted by 2 infectious diseases (ID) providers for 29 patients, ages 17 months-15 years, with complex infections. Total estimated time spent on CC was 54 hours, equivalent to at least 6 workdays. Five patients with complex social issues used 37% of total CC time. Of 129 phone events, 38% involved direct contact with families, pharmacies (13%), primary care providers (13%), and home health nursing (11%). Care coordination prevented 10 emergency room (ER) visits and 2 readmissions. Care coordination led to 16 additional, not previously scheduled subspecialist and 13 primary care visits. The OPAT providers billed for 32 clinic visits during the study period. CONCLUSIONS Nonreimbursable CC work by OPAT providers prevented readmissions and ER visits and helped facilitate appropriate healthcare use. The value of pediatric OPAT involvement in patient care would have been underestimated based on reimbursable ID consultations and clinic visits alone.
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Affiliation(s)
- Louise E Vaz
- Division of Pediatric Infectious Diseases, Doernbecher Children’s Hospital,Correspondence: L. Vaz, MD, MPH, Division of Pediatric Infectious Diseases, Doernbecher Children’s Hospital, Oregon Health and Science University, Mail Code CDRC-P, 707 SW Gaines, St. Portland, OR 97239 ()
| | - Cindi L Farnstrom
- Division of Pediatric Infectious Diseases, Doernbecher Children’s Hospital
| | - Kimberly K Felder
- Division of Infectious Diseases, Oregon Health & Science University, Portland
| | | | - Hannah Rosenberg
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Massachusetts
| | - Richard C Antonelli
- Division of General Pediatrics, Department of Medicine, Boston Children’s Hospital, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Langer CS, Antonelli RC, Chamberlain L, Pan RJ, Keller D. Evolving Federal and State Health Care Policy: Toward a More Integrated and Comprehensive Care-Delivery System for Children With Medical Complexity. Pediatrics 2018; 141:S259-S265. [PMID: 29496977 DOI: 10.1542/peds.2017-1284k] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2017] [Indexed: 11/24/2022] Open
Abstract
Irrespective of any future changes in federal health policy, the momentum to shift from fee-for-service to value-based payment systems is likely to persist. Public and private payers continue to move toward alternative payment models that promote novel care-delivery systems and greater accountability for health outcomes. With a focus on population health, patient-centered medical homes, and care coordination, alternative payment models hold the potential to promote care-delivery systems that address the unique needs of children with medical complexity (CMC), including nonmedical needs and the social determinants of health. Notwithstanding, the implementation of care systems with meaningful quality measures for CMC poses unique and substantive challenges. Stakeholders must view policy options for CMC in the context of transformation within the overall health system to understand how broader health system changes impact care delivery for CMC.
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Affiliation(s)
- Carolyn S Langer
- Office of Clinical Affairs, Commonwealth Medicine, University of Massachusetts Medical School, Worcester, Massachusetts;
| | - Richard C Antonelli
- Boston Children's Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
| | | | | | - David Keller
- Children's Hospital Colorado, School of Medicine, University of Colorado, Aurora, Colorado
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Affiliation(s)
- Richard C Antonelli
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts; .,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Renee M Turchi
- Department of Pediatrics, St Christopher's Hospital for Children, Philadelphia, Pennsylvania; and.,Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, Pennsylvania
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Fleischman A, Hourigan SE, Lyon HN, Landry MG, Reynolds J, Steltz SK, Robinson L, Keating S, Feldman HA, Antonelli RC, Ludwig DS, Ebbeling CB. Creating an integrated care model for childhood obesity: a randomized pilot study utilizing telehealth in a community primary care setting. Clin Obes 2016; 6:380-388. [PMID: 27863024 PMCID: PMC5523655 DOI: 10.1111/cob.12166] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 09/09/2016] [Accepted: 09/18/2016] [Indexed: 11/29/2022]
Abstract
In an integrated care model, involving primary care providers (PCPs) and obesity specialists, telehealth may be useful for overcoming barriers to treating childhood obesity. We conducted a pilot study comparing body mass index (BMI) changes between two arms (i) PCP in-person clinic visits plus obesity specialist tele-visits ( PCP visits + specialist tele-visits) and (ii) PCP in-person clinic visits only ( PCP visits only), with ongoing tele-consultation between PCPs and obesity specialists for both arms. Patients (N = 40, 10-17 years, BMI ≥ 95th percentile) were randomized to Group 1 or 2. Both groups had PCP visits every 3 months for 12 months. Using a cross-over protocol, Group 1 had PCP visits + specialist tele-visits during the first 6 months and PCP visits only during the second 6 months, and Group 2 followed the opposite sequence. Each of 12 tele-visits was conducted by a dietitian or psychologist with a patient and parent. Retention rates were 90% at 6 months and 80% at 12 months. BMI (z-score) decreased more for Group 1 (started with PCP visits + specialist tele-visits) vs. Group 2 (started with PCP visits only) at 3 months (-0.11 vs. -0.05, P = 0.049) following frequent tele-visits. At 6 months (primary outcome), BMI was lower than baseline within Group 1 (-0.11, P = 0.0006) but not Group 2 (-0.06, P = 0.08); however, decrease in BMI at 6 months did not differ between groups. After crossover, BMI remained lower than baseline for Group 1 and dropped below baseline for Group 2. An integrated care model utilizing telehealth holds promise for treating children with obesity.
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Affiliation(s)
- Amy Fleischman
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Helen N. Lyon
- Wareham Pediatric Associates, Wareham, Massachusetts
| | - Melissa Gallagher Landry
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
| | | | - Sarah K. Steltz
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
| | - Lisa Robinson
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
| | | | | | | | - David S. Ludwig
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
| | - Cara B. Ebbeling
- New Balance Foundation Obesity Prevention Center, Division of Endocrinology, Boston Children’s Hospital, Boston, Massachusetts
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Ziniel SI, Rosenberg HN, Bach AM, Singer SJ, Antonelli RC. Validation of a Parent-Reported Experience Measure of Integrated Care. Pediatrics 2016; 138:peds.2016-0676. [PMID: 27940672 DOI: 10.1542/peds.2016-0676] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/27/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objectives of this study were to design and validate a survey measuring the parents' and caregivers' experiences of integration of their child's care across providers. METHODS After review of the literature on care coordination and integration, we solicited input regarding care experiences from focus groups of families with children with chronic conditions. These data informed a 95-item pilot survey that included elements from a care integration measure designed for adult care experiences. The survey was then administered to parents of children who had had at least 1 primary care appointment and 2 specialty care appointments in the previous 12 months. Psychometric analyses were used to establish scales through exploratory factor analysis, internal consistency using Cronbach's α, test-retest reliability using Spearman's rank correlation coefficient, and known-group validity according to χ2 tests. All research activities were institutional review board approved. RESULTS The pilot survey was completed as either a Web or mail survey by 255 participants. After excluding nonrating or screening questions and items not applicable to a large percentage of participants, 26 experience items were included in the exploratory factor analysis. The final survey contained 19 experience items in 5 scales: access, communication, family impact, care goal creation, and team functioning. Psychometric analyses supported these 5 scales. CONCLUSIONS This project developed and validated a survey with 19 experience items, plus additional demographic and health needs and usage items. The Pediatric Integrated Care Survey can be used in quality improvement efforts to measure family-reported experience of pediatric care integration.
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Affiliation(s)
- Sonja I Ziniel
- Center for Patient Safety and Quality Research, Program for Patient Safety and Quality.,Division of Adolescent and Young Adult Medicine.,Departments of Pediatrics and.,Pediatric Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Hannah N Rosenberg
- Division of General Pediatrics, Department of Medicine, and.,Integrated Care Program, Boston Children's Hospital, Boston, Massachusetts
| | - Ashley M Bach
- Division of General Pediatrics, Department of Medicine, and
| | - Sara J Singer
- Medicine, Harvard Medical School, Boston, Massachusetts.,Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; and.,Mongan Institute for Health Policy, Massachusetts General Hospital, Boston, Massachusetts
| | - Richard C Antonelli
- Departments of Pediatrics and .,Division of General Pediatrics, Department of Medicine, and.,Integrated Care Program, Boston Children's Hospital, Boston, Massachusetts
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Ferrari LR, Ziniel SI, Antonelli RC. Perioperative Care Coordination Measurement: A Tool to Support Care Integration of Pediatric Surgical Patients. ACTA ACUST UNITED AC 2016; 6:130-6. [PMID: 26517234 DOI: 10.1213/xaa.0000000000000246] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The relationship of care coordination activities and outcomes to resource utilization and personnel costs has been evaluated for a number of pediatric medical home practices. One of the first tools designed to evaluate the activities and outcomes for pediatric care coordination is the Care Coordination Measurement Tool (CCMT). It has become widely used as an instrument for health care providers in both primary and subspecialty care settings. This tool enables the user to stratify patients based on acuity and complexity while documenting the activities and outcomes of care coordination. We tested the feasibility of adapting the CCMT to a pediatric surgical population at Boston Children's Hospital. The tool was used to assess the preoperative care coordination activities. Care coordination activities were tracked during the interval from the date the patient was scheduled for a surgical or interventional procedure through the day of the procedure. A care coordination encounter was defined as any task, whether face to face or not, supporting the development or implementation of a plan of care. Data were collected to enable analysis of 5675 care coordination encounters supporting the care provided to 3406 individual surgical cases (patients). The outcomes of care coordination, as documented by the preoperative nursing staff, included the elaboration of the care plan through patient-focused communication among specialist, facilities, perioperative team, and primary care physicians in 80.5% of cases. The average time spent on care coordination activities increased incrementally by 30 minutes with each additional care coordination encounter for a surgical case. Surgical cases with 1 care coordination encounter took an average of 35.7 minutes of preoperative care coordination, whereas those with ≥4 care coordination encounters reported an average of 121.6 minutes. We successfully adapted and implemented the CCMT for a pediatric surgical population and measured nonface-to-face, nonbillable encounters performed by perioperative nursing staff. The care coordination activities integrated into the preoperative process include elaboration of care plans and identification and remediation of discrepancies. Capturing the activities and outcomes of care coordination for preoperative care provides a framework for quality improvement and enables documentation of the value of nonface-to-face perioperative nursing encounters that comprise care coordination.
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Affiliation(s)
- Lynne R Ferrari
- From the *Department of Anesthesia, Harvard Medical School, Boston, Massachusetts; †Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts; ‡Program for Patient Safety and Quality, Center for Patient Safety and Quality Research, Boston Children's Hospital, Boston, Massachusetts; §Department of Pediatrics, Harvard Medical School, Boston, Massachusetts; and ‖Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
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14
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Affiliation(s)
| | - Richard C Antonelli
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Massachusetts
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Sharma N, O’Hare K, Antonelli RC, Sawicki GS. Transition care: future directions in education, health policy, and outcomes research. Acad Pediatr 2014; 14:120-7. [PMID: 24602574 PMCID: PMC4098714 DOI: 10.1016/j.acap.2013.11.007] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 11/08/2013] [Accepted: 11/12/2013] [Indexed: 12/19/2022]
Abstract
All youth must transition from pediatric to adult-centered medical care. This process is especially difficult for youth with special health care needs. Many youth do not receive the age-appropriate medical care they need and are at risk during this vulnerable time. Previous research has identified barriers that may prevent effective transition, and protocols have been developed to improve the process. Health outcomes related to successful transition have yet to be fully defined. Health care transition can also be influenced by education of providers, but there are gaps in medical education at the undergraduate, graduate, and postgraduate levels. Current changes in federal health policy allow improved health care coverage, provide some new financial incentives, and test new structures for transitional care, including the evolution of accountable care organizations (ACO). Future work must test how these systems changes will affect quality of care. Finally, transition protocols exist in various medical subspecialties; however, national survey results show no improvement in transition readiness, and there are no consistent measures of what constitutes transition success. In order to advance the field of transition, research must be done to integrate transition curricula at the undergraduate, graduate, and postgraduate levels; to provide advance financial incentives and pilot the ACO model in centers providing care to youth during transition; to define outcome measures of importance to transition; and to study the effectiveness of current transition tools on improving these outcomes.
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Affiliation(s)
- Niraj Sharma
- Division of General Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Mass; Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Boston, Mass.
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Abstract
Existing research suggests that models of enhanced primary care lead to health care systems with better performance. What the research does not show is whether such an approach is feasible or likely to be effective within the U.S. health care system. Many commentators have adopted the model of the patient-centered medical home as policy shorthand to address the reinvention of primary care in the United States. We analyze potential barriers to implementing the medical home model for policy makers and practitioners. Among others, these include developing new payment models, as well as the need for up-front funding to assemble the personnel and infrastructure required by an enhanced non-visit-based primary care practice and methods to facilitate transformation of existing practices to functioning medical homes.
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Affiliation(s)
- Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, MA, USA.
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Landon BE, Gill JM, Antonelli RC, Rich EC. Using evidence to inform policy: developing a policy-relevant research agenda for the patient-centered medical home. J Gen Intern Med 2010; 25:581-3. [PMID: 20467906 PMCID: PMC2869407 DOI: 10.1007/s11606-010-1303-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Bruce E Landon
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA.
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Gill JM, Landon BE, Antonelli RC, Rich EC. Generating the knowledge needed to make the patient-centered medical home a reality: a collaborative project of the primary care specialties. Ann Fam Med 2010; 8:88-9. [PMID: 20065286 PMCID: PMC2807398 DOI: 10.1370/afm.1087] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- James M Gill
- Delaware Valley Outcome Research and Jefferson Medical College, USA
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Affiliation(s)
- Steven E Wegner
- AccessCare, 3500 Gateway Centre Blvd, ste. 130, Morrisville, NC 27560, USA.
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Affiliation(s)
- Jeanne W McAllister
- Center for Medical Home Improvement, Crotched Mountain Foundation, Concord, New Hampshire, USA.
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Abstract
The concept of a medical home appears to be a key driver for enhancing the value of health services as care systems are transitioned to meet the ongoing challenges of improving quality and containing costs. This article provides an overview of the challenges faced in United States health care delivery systems that affect child health, explains how the medical home might address them, describes methods for measuring quality in medical homes, and identifies barriers to implementation of the model.
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Affiliation(s)
- Steven E Wegner
- AccessCare, 3500 Gateway Centre Boulevard, Suite 130, Morrisville, NC 27560-8501, USA.
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Antonelli RC, Stille CJ, Antonelli DM. Care coordination for children and youth with special health care needs: a descriptive, multisite study of activities, personnel costs, and outcomes. Pediatrics 2008; 122:e209-16. [PMID: 18595966 DOI: 10.1542/peds.2007-2254] [Citation(s) in RCA: 133] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Objectives included testing use of the care-coordination measurement tool in pediatric primary care practices; describing care-coordination activities for children and youth that occur in primary care practices; assessing the relationship of care-coordination activities in the medical home with outcomes related to resource use; and measuring the direct personnel costs of care-coordination activities. METHODS Six general pediatric practices were selected, representing a diverse range of sizes, locations, patient demographics, and care-coordination activity model types. The care-coordination measurement tool was used over a period of 8 months in 2003 to record all of the nonreimbursable care-coordination activity encounters performed by any office-based personnel. The tool enabled recording of activities, resources-use outcomes, and time. Cost of personnel performing care-coordination activities was derived by extrapolation from the time spent. RESULTS Care-coordination activity services were used by patients of all complexity levels. Children and youth with special health care needs with acute-onset, family-based psychosocial problems experienced 14% of the care-coordination activity encounters and used 21% of the care-coordination activities minutes. Children and youth without special health care needs, without complicating family psychosocial problems, received 50% of the encounters and used 36% of the care-coordination activity minutes. The average cost per care-coordination activity encounter varied from $4.39 to $12.86, with an overall mean of $7.78. A principal cost driver seemed to be the percentage of care-coordination activities performed by physicians. Office-based nurses prevented a large majority of emergency department visits and episodic office visits. CONCLUSIONS Care-coordination activity was assessed at the practice level, and the care-coordination measurement tool was used successfully during the operations of typical, pediatric, primary care settings. The presence of acute, family-based social stressors was a significant driver of need for care-coordination activities. A high proportion of dependence on care-coordination performed by physicians led to increased costs. Office-based nurses providing care coordination were responsible for a significant number of episodes of avoidance of higher cost use outcomes.
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Affiliation(s)
- Richard C Antonelli
- Division of Academic General Pediatrics, Connecticut Children's Medical Center, University of Connecticut School of Medicine, Hartford, Connecticut 06106, USA.
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Connor DF, McLaughlin TJ, Jeffers-Terry M, O'Brien WH, Stille CJ, Young LM, Antonelli RC. Targeted child psychiatric services: a new model of pediatric primary clinician--child psychiatry collaborative care. Clin Pediatr (Phila) 2006; 45:423-34. [PMID: 16891275 DOI: 10.1177/0009922806289617] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Between 15% and 25% of children and adolescents seen in pediatric primary care have a behavioral health disorder with significant psychopathology, high functional impairment, and frequent psychiatric diagnostic comorbidity. Because child psychiatry services are frequently unavailable, primary care clinicians are frequently left managing these children without access to child psychiatry consultation. We describe Targeted Child Psychiatric Services (TCPS), a new model of pediatric primary clinician-child psychiatry collaborative care, and describe program utilization and characteristics of children referred over the first 18 months of the program using a retrospective chart review. The TCPS model can serve a large number of pediatric primary care practices and provide collaborative help with the evaluation and treatment of complex attention deficit hyperactivity disorder, depression, anxiety disorders, and pediatric psychopharmacology.
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Affiliation(s)
- Daniel F Connor
- Department of Psychiatry, Division of Child and Adolescent Psychiatry and Pediatrics, University of Massachusetts Medical School, Worcester, MA, USA
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Abstract
PURPOSE OF REVIEW Coordination of care is an essential function of pediatric primary care, needed most by children with special health care needs (CSHCN). Although complex, its necessity has become better recognized with the recent increase in attention in the United States to the comprehensive "medical home" model of care. RECENT FINDINGS Coordination is highly dependent on effective communication within the health care system and between the health care system and the larger community. While coordination may best be undertaken at the level of the physician practice, a team approach involving nonphysician staff and families as primary participants may be the best option in many cases. More attention is being paid at the health policy level to the implementation of coordination of care, although solutions to reimbursement barriers have yet to be implemented. Considerable progress on methods to improve care coordination in the primary care practice setting has been made recently. Many of these efforts have used quality improvement techniques adapted from the business world. Emerging measures of the process of care coordination are also being developed, although few studies have been published to date showing a positive impact of care coordination. SUMMARY The value of coordination of care as an essential part of medical care for children with special health care needs is becoming widely recognized. Methods to implement it within pediatric primary care practices are being developed, although more data demonstrating its value are needed to inform policy changes.
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Affiliation(s)
- Christopher J Stille
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
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Antonelli RC, Antonelli DM. Providing a medical home: the cost of care coordination services in a community-based, general pediatric practice. Pediatrics 2004; 113:1522-8. [PMID: 15121921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVE To determine the cost of unreimbursable care coordination services for children with special health care needs (CSHCN) in 1 community-based, general pediatric practice. METHODS A measurement tool was developed to quantify the precise activities involved in providing comprehensive, coordinated care for CSHCN. Costs of providing this care were calculated on the basis of time spent multiplied by the average salary of the office personnel performing the care coordination service. In addition, data were collected regarding the complexity level of the patient requiring the service, the type of service provided, and the outcome. RESULTS During the 95-day study period, 774 encounters that led to care coordination activities were logged, representing service provision to 444 separate patients. When these encounters were examined on the basis of clinical complexity of the patient, the most complex patients constituted 11% of the population of CSHCN yet accounted for 25% of the encounters. In addition, care coordination activities for these clinically complex CSHCN engaged office staff 4 times as long when compared with less clinically complex CSHCN. Overall, 51% of the encounters were attributable to coordinating care for problems not considered typically medical and included activities such as processing referrals with managed care organizations, consulting with schools or other educational programs, and providing oversight for psychosocial issues. On the basis of national salary and benefits data, the annual cost of the time spent coordinating care for CSHCN in this medical home model ranged from 22,809 dollars to 33,048 dollars (representing the 25th and 75th percentiles, respectively). CONCLUSIONS The costs of providing care coordination services to CSHCN in a medical home are appreciable but not prohibitive. Standardization of care coordination practices is essential because it makes the medical home more amenable to quality improvement interventions. Mechanisms to finance unreimbursable care coordination activities must be developed to achieve the Healthy People 2010 objective that all CSHCN have access to a medical home.
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Affiliation(s)
- Richard C Antonelli
- Nashaway Pediatrics, University of Massachusetts Memorial Community Medical Group, Sterling, Massachusetts, USA
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