A comprehensive approach to caring for hospitalized ... · • Hydrocephalus s/p...
Transcript of A comprehensive approach to caring for hospitalized ... · • Hydrocephalus s/p...
March, 2015
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A comprehensive approach to caring for hospitalized medically
complex patients
Ndidi Unaka, MDChristine White MD, MAT
Cincinnati Children’s Hospital Medical Center
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Objectives
• Highlight importance of coordination in caring for medically complex patients
• Describe strategies for providing hospitalized medically complex patients comprehensive care
• Identify barriers/corresponding solutions to developing comprehensive care team models
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Complex Care Patient4 year old male with chromosomal disorder
• Severe neurologic impairment• Hydrocephalus s/p Ventriculoperitoneal shunt• Epilepsy (on multiple antiepileptic drugs)• GT dependent (s/p Nissen)• Cleft lip and palate s/p repair• Chronic respiratory failure (tracheostomy and BiPAP dependent)• Hypothyroidism• Spasticity
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Specialists Involved• Complex Care Center• Neurology• GI• ENT• Pulmonary• Physical Medicine & Rehab• Plastic Surgery• Endocrinology
Utilization• 7 medical admissions in last
year• 50 inpatient days• 5 ICU bed days• Average of 3 consults/admit• Average of 25 discharge
medications
Complex Care Patient
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Definition: Children with Complex Medical Needs• Children with complex medical needs rapidly growing
population• Group includes children with:
– A clearly identified medical specialty home – Neurologic impairment – Technology dependence
Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. Mar 2011;127(3):529-538.Berry JG, Hall M, Hall DE, et al. Inpatient Growth and Resource Use in 28 Children's Hospitals: A Longitudinal, Multi-institutional Study. Arch. Pediatr. Adolesc. Med. Dec 24 2012:1-9.
Definition
Gastrostomy tube
Tracheostomy tube
Neurologic impairment (ex: cerebral palsy, brain injury)
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At Risk Population
• High utilization of hospital resources• Increasing admissions• At risk for medication errors• Limited longitudinal handoff between
inpatient and outpatient providers
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Our History
2011 2013
Complex patients distributed amongst all 5 HM teams Creation of New
Complex Care Team
Remainder of neurologically impaired and technology dependent patients distributed among other 4 HM teams
-Staffed by HM attendings (350 pts/year)
-Patients from Complex Care clinic designated to one HM team
-Staffed by Complex Care Clinic attending (105 patients/year)
-Other general HM patients also on team
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Complex Care Team• Created to provide specialized care to this unique
patient population• All patients who are neurologically impaired or
technology dependent admitted onto 1 HM team, including
• Complex Care Clinic patients• Palliative Care patients• Transition Adult Care Patients
• Maximum 9 Patients
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Rationale for the Creation of an Inpatient Medical Home • Improve care coordination• Provide more family centered care• Improve the safety of this high risk population• Develop a core group of HM attendings with expertise
and investment in caring for patients with complex medical needs
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Multidisciplinary Rounds
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• Specific Care coordination rounds once/week
• Medication reconciliation rounds 2x/week
• Multidisciplinary verbal attending handoff each Friday with outpatient providers
Care Coordination/Safety
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Family-Centered Care
• Very positive feedback from families:– “I feel like things get done faster now”
– “Yellow team has been the best thing that happened to my daughter since we have been here”
– “You guys said you talked to my pediatricians in complex care clinic and the rehabilitation physicians but I didn’t believe it until I saw you in rounds together. This makes me feel great”
– “Is discharge always this easy?”
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Outcomes: Discharge EfficiencyPrior Work
Physicians define
medical criteria in EHR on
admission
Patient meets
medically-ready criteria
Nurse places time stamp in
EHR
Goal to leave within 2 hours of
meeting all criteria
• Patient-focused around disease process improvement• Do not aim for an arbitrary time of day
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Frontline Staff Engagement
Consult Timeliness
Pharmacy Process Change
How will this process apply to complex patients
with unique discharge needs?
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SMART Aim
Increase the percentage of medically complex pediatric patients discharged within 2 hours* of meeting medically ready criteria from 50% to
80% by September 1, 2014
*If criteria were met between 8:00pm – 7:00am, patients were not expected to leave until 9am
Key Drivers
Increase the percentage of
medically complex pediatric patients
discharged within 2 hours of meeting medically ready
criteria from 50% to 80% by
September 1, 2014
Anticipation of Discharge Care Needs
Staff Engagement in Discharge Preparedness
Care Coordination
Optimization of Team Structure
Discharge Goal Identification
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Run Chart
Cohort Patients on Complex
Care Team
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Run Chart
Cohort Patients on Complex
Care Team
Creation of Complex Care
Admission Order Set
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Complex Care Order Set
© 2013 Epic Systems Corporation. Used with permission.
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Weekly Multidisciplinary
Care Coordination
Rounds
Medication Pathway
Needs Assessment Tool and Reminders
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Needs Assessment Tool
• Equipment• Home Health Care
Needs • Private Duty Nursing• Transportation
• Medications• Follow-up
Appointments• Social/Family
Concerns• Education Needs
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Run Chart
Weekly Multidisciplinary
Care Coordination Rounds
Needs Assessment
Tool and Reminders
Medication Pathway
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Future Directions
• Adapt and improve current processes in place• Developing communication tools for families and
clinicians across the continuum of care• Tools for while kids are hospitalized AND in the
transition home
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Barriers
• Lack of ancillary support• Institutional buy in
• Financial support• Faculty, resident, and nursing comfort with
caring for patients with complex medical needs• Time• Lack of outpatient and subspecialty partners
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Strategies
• The ideal?– Define the role of the primary care physician
• Rounds on the first day of admission in which the PMD and hospitalist are both present
– Optimize the role of subspecialists• Integration of primary subspecialists’ thoughts into the
plan of care
– Provide support for families during long hospitalizations and transitions of care
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Resident Curriculum• Trach/G-Tube Practical Discussion• DNR/DNI/Hospice• General approach to patient with special needs• A Day in the Life of a Special Needs Parent• Common Overnight Mommy Calls/Emergencies • Nutritional Concerns in Special Needs patients• Management of Patients with Cerebral Palsy• Autonomic Storming• Ethics/Month-End Debrief
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Secondary Outcomes
• Median LOS: 3.1 days to 2.2 days (p = .13)
• Readmission rates: 31% to 22% (p = .23)