Development of a New Care Model for Hospitalized Children With Medical Complexity

Abstract

Children with medical complexity are a rapidly growing inpatient population with frequent, lengthy, and costly hospitalizations. During hospitalization, these patients require care coordination among multiple subspecialties and their outpatient medical homes. At a large freestanding children's hospital, a new inpatient model of care was developed in an effort to consistently provide coordinated, family-centered, and efficient care. In addition to expanding the multidisciplinary team to include a pharmacist, dietician, and social worker, the team redesign included: (1) medication reconciliation rounds, (2) care coordination rounds, and (3) multidisciplinary weekly handoff with outpatient providers. During weekly medication reconciliation rounds, the team pharmacist reviews each patient's current medications with the team. In care coordination rounds, the team collaborates with unit care managers to identify discharge needs and complete discharge tasks. Finally, at the end of the week, the outgoing hospital medicine attending physician hands off patient care to the incoming attending with input from the team's pharmacist, dietician, and social worker. Families and providers noted improvements in care coordination with the new care model. Remaining challenges include balancing resident autonomy and attending supervision, as well as supporting providers in delivering care that can be emotionally challenging. Aspects of this care model could be tested and adapted at other hospitals that care for children with medical complexity. Additionally, future work should study the impact of inpatient complex care models on patient health outcomes and experience.

Postdischarge Nurse Home Visits and Reuse: The Hospital to Home Outcomes (H2O) Trial

“…30 Medical complexity was determined by the patient's hospitalization service and was as follows: "non-complex" patients were hospitalized on the hospital medicine general services, whereas "complex" patients were hospitalized on the neurosciences services or the hospital medicine complex care service, which cares for children with technology dependency or significant neurologic impairment. 31 If the child was randomly assigned to the intervention group, the intervention nurse team was notified to schedule the nurse visit.…”

Improving Hospital-to-Home Transitions for Children Entering Foster Care

“…Although total numbers of children discharged into foster care are relatively small, these children are one of our most vulnerable populations, many of whom have already suffered from conditions of neglect or abuse. Although authors of several pediatric hospital-to-home research collaboratives are focusing on the needs and outcomes of medically complex children, [2][3][4] to our knowledge, this is the first study used to focus on this socially complex population. With our analysis, we suggest that we are less likely to implement efforts to support hospital-to-home transitions for children discharged with new foster caregivers compared with children discharged with their preadmission caregivers, which may lead to increased morbidity and caregiver stress.…”

“…Hospital-to-home transitions present wellrecognized safety risks, and children who are medically and socially complex are particularly vulnerable to poor outcomes. 1 Although children with medical complexity are the focus of several ongoing improvement efforts in this area, [2][3][4] there are fewer efforts aimed at children with social risk factors. More than 400 000 children are currently in foster care in the United States 5 ; these children are, by definition, socially complex and have higher rates of developmental delay, mental illness, and chronic health conditions than children from similar socioeconomic backgrounds not in foster care.…”

The Intersection of Complex Care and Hospital Medicine: Opportunities to Advance Health for Chronically Ill Populations

“…Practical steps that hospitalists can take include implementing new tools in the hospital (eg, shared plans of care), 18 leading efforts to strengthen transitions of care between home and hospital, integration with outpatient complex care, community and specialty providers, and advocacy for interdisciplinary inpatient care models. 9 The traditional inpatient care system was not designed to optimize health for CMC; however, practicing hospitalists are changemakers well positioned to adapt processes to better meet their unique needs across their life course.…”