BackgroundPrimary care medical homes may improve health outcomes for children with special healthcare needs (CSHCN), by improving care coordination. However, community-based primary care practices may be challenged to deliver comprehensive care coordination to complex subsets of CSHCN such as children with medical complexity (CMC). Linking a tertiary care center with the community may achieve cost effective and high quality care for CMC. The objective of this study was to evaluate the outcomes of community-based complex care clinics integrated with a tertiary care center.MethodsA before- and after-intervention study design with mixed (quantitative/qualitative) methods was utilized. Clinics at two community hospitals distant from tertiary care were staffed by local community pediatricians with the tertiary care center nurse practitioner and linked with primary care providers. Eighty-one children with underlying chronic conditions, fragility, requirement for high intensity care and/or technology assistance, and involvement of multiple providers participated. Main outcome measures included health care utilization and expenditures, parent reports of parent- and child-quality of life [QOL (SF-36®, CPCHILD©, PedsQL™)], and family-centered care (MPOC-20®). Comparisons were made in equal (up to 1 year) pre- and post-periods supplemented by qualitative perspectives of families and pediatricians.ResultsTotal health care system costs decreased from median (IQR) $244 (981) per patient per month (PPPM) pre-enrolment to $131 (355) PPPM post-enrolment (p=.007), driven primarily by fewer inpatient days in the tertiary care center (p=.006). Parents reported decreased out of pocket expenses (p<.0001). Parental QOL did not significantly change over the course of the study. Child QOL improved between baseline and 6 months in two PedsQL™ domains [Social (p=.01); Emotional (p=.003)], and between baseline and 1 year in two CPCHILD© domains [Health Standardization Section (p=.04); Comfort and Emotions (p=.03)], while total CPCHILD© score decreased between baseline and 1 year (p=.003). Parents and providers reported the ability to receive care close to home as a key benefit.ConclusionsComplex care can be provided in community-based settings with less direct tertiary care involvement through an integrated clinic. Improvements in health care utilization and family-centeredness of care can be achieved despite minimal changes in parental perceptions of child health.

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These results highlight the need to redesign current heart failure patient education initiatives to enhance patient outcomes.

Student nurses often embark on their professional careers with a lack of the knowledge and confidence necessary to navigate them successfully. An ongoing process of career planning and development (CPD) is integral to developing career resilience, one key attribute that may enable nurses to respond to and influence their ever-changing work environments with the potential outcome of increased job satisfaction and commitment to the profession. A longitudinal mixed methods study of a curriculum-based CPD program was conducted to determine the program's effects on participating students, new graduate nurses, and faculty. This first in a series of three papers about the overall study's components reports on undergraduate student outcomes. Findings demonstrate that the intervention group reported higher perceived career resilience than the control group, who received the standard nursing curriculum without CPD. The program offered students the tools and resources to become confident, self-directed, and active in shaping their engagement in their academic program to help achieve their career goals, whereas control group students continued to look uncertainly to others for answers and direction. The intervention group recognized the value of this particular CPD program and both groups, albeit differently, highlighted the key role that faculty played in students' career planning.