Care Coordination in Pediatric Practices: Overview

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Care Coordination in Pediatric Practices: Overview
Care co-ordination in Complex
Care Medical Home
Practical Considerations
Rahel Berhane, MD
May 12, 2017
Medical Home for Special
Populations
Examples
– Complex Care Medical Home
– Foster care centers of excellence
Rationale
- What care gaps does it fill?
Value
- Is it worth the extra cost?
Multi-disciplinary Team
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Pediatrician
Advanced Practice Nurses
Registered Nurses
Child Life Specialists
Social Workers
Dietitians
Community Health workers
Navigators; Referral coordinators
Care co-ordination
• Two distinct but overlapping processes
– Clinical care coordination
– Cross-sector care coordination (systems of
care)
Vignette #1
Clinical Care coordination
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PNP – VM
Patient – Anna Brown, 3 years old
Office visit – Post hospitalization follow up
Reason for hospitalization- Pneumonia
Back History: Diaphragmatic hernia; S/P ECMO;
S/P G-tube fundoplication. Most recent admission for
pneumonia. Currently on antibiotics. Improving.
Clinical care co-ordination
Pre-visit review
NP-VM deeply concerned about recurrent
pneumonia (3rd admission in as many
months).
- Reviews CXRs
- Reviews Discharge summary
- Reviews notes from pulmonology
Clinical care co-ordination
- Reviews current status with family
- Discusses possible factors for recurrence
- Calls pulmonologist to review
Assessment: Ongoing GERD through failed
fundoplication
Recommendation: GJ feedings vs Repair
fundoplication
Actions: Change care plan; Review with home
health nurses
Vignette #2
Clinical Care co-ordination
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Emma Smith (PCP- AR)
Reason for appointment: Pre-op Physical
Reason for surgery – Bilateral dislocated hips
Back history- 8 years old; Spastic
quadriplegia. Recent onset of unexplained
irritability
Clinical Care co-ordination
• PCP- AR
Pre-visit review: Reviews X-rays; Reviews
notes from orthopedists
Visit: Explores symptoms the surgery is expected
to fix; Explores with family about risks and
expectations
Post visit: Calls specialist; clarifies patients’
goals of care and findings from X-ray three years
ago
Vignette #3
Clinical Care Coordination
• PCP: JM – PNP
• Back History: 18 month old, Hemiplegia,
traumatic brain injury, coagulopathy, past history
of LE thrombus
• Reason for call: Family called clinic to inform
that they will be heading to the ED as there was
concern for a clot and hematology had advised
them to go to ED in this scenario
Clinical Care coordination
• JM-PNP advised the family to stop by in
clinic for a quick evaluation
• Preformed full perfusion focused exam;
Sent for stat Doppler LE X2. No clots, no
issues
• Called hematology clinic to notify;
forwarded all information to hematologist.
Clinical Care co-ordination
Three elements
#1. Longitudinal relationship/Empathy
(Does this intervention align with the family’s goals?)
#2. Curiosity and Clinical Judgment
(Review data; trends and aberrations)
#3. Confidence to question other providers
( Are you aware of this event in this patient’s past?)
Multi-disciplinary Team
•
•
•
•
•
•
•
•
Pediatrician
Advanced Practice Nurses
Registered Nurses
Child Life Specialists
Social Workers
Dietitians
Community Health workers
Navigators; Referral coordinators
Clinical Care co-ordination
- Meaningful care coordination is best done
by the provider
- Very time-intensive. Not always ‘
encounter based’
- Requires different workflow and team
organization
Clinical Care co-ordination
• How to measure
– Currently largely not reimbursed by insurance
– Efforts to increase time spent on encounters
misguided and lead to erosion of quality
– Pay for process?
– Pay for outcome?
Care co-ordination
• Two distinct but overlapping processes
– Clinical care coordination
– Cross-sector care coordination (systems of
care)
Systems of care
• Coordination to implement care plan
(Coordination with DME, Therapy and home health agencies;
Referral authorization; System navigation)
• Coordination with school
• Coordination with social service agencies
Care coordination/Case
Management
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NICU case manager
ECI service coordinator
MCO service coordinator
Specialty clinic case manager
School – Special education service
coordinator
IDD Service Providers- Austin,
TX
Case
Management
Behavioral
Health
Community
Medical
(PCP/Specialist)
Therapy/
Habilitation
• Multidisciplinary
assessment
• Annual Care plan Update
and goal setting
• Person-centered planning
Community/
Life
Case Manager
Behavioral
• Data sharing across
sectors
• Case Management and
service coordination tied
to the patient (not agency
or service line)
• Collective accountability
for outcomes
Patient/ Family
Medical
Future Direction
• Measure value of clinical care coordination
– Commitment from HHSC and STARKIDS MCOs
– Standardize patient stratification/complexity
– Embed rigorous evaluation
• Systems of care – pilot
– Streamline workflow
– Standardize outcome measures
– Align incentives

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