Hospital Consultation From Outpatient Clinicians for Medically Complex Children

Abstract

IMPORTANCEChildren with medical complexity (CMC) frequently experience fragmented care. We have demonstrated that outpatient comprehensive care (CC) reduces serious illnesses, hospitalizations, and costs for high-risk CMC. Yet continuity of care for CMC is often disrupted with emergency department (ED) visits and hospitalizations.OBJECTIVE To evaluate a hospital consultation (HC) service for CMC from their outpatient CC clinicians.DESIGN, SETTING, AND PARTICIPANTS Randomized quality improvement trial at the University of Texas Health Science Center at Houston with an outpatient CC clinic and tertiary pediatric hospital (Children's Memorial Hermann Hospital). Participants included high-risk CMC (Ն2 hospitalizations or Ն1 pediatric intensive care unit [PICU] admission in the year before enrolling in our clinic) receiving CC. Data were analyzed between January 11, 2018, and

Telemedicine for Children With Medical Complexity: A Randomized Clinical Trial

“…CC was provided to all trial participants to promote prompt effective care at all hours. As previously detailed, [6][7][8] CC included highly experienced PCPs and subspecialists working in the same clinic, 24/7 access to the clinic emergency cell phone that is rotated between the PCPs, same-day care on weekdays in the clinic for acute illnesses and complications, a low patient-to-PCP ratio (#100:1), weekly scrutiny of the care received before any ED visit or hospitalization, and a hospital consultation service from the CC providers during hospitalizations in our primary teaching hospital, the Children's Memorial Hermann Hospital (CMHH). 8…”

“…At the study outset, telemedicine had not been used in any pediatric clinic in our center, and the parents often declined to have telemedicine visits. In addition, our PCPs who were all experienced in communicating with patients by telephone at all hours 7,8 were initially skeptical that telemedicine would add much benefit to CC. In promoting use of telemedicine, the weekly meetings between the medical director (R.M.)…”

“…As a result, CC has substantially reduced serious illnesses, hospital days, PICU days, and health system costs for medically complex children in our center. [6][7][8] Even so, their need for medical attention and the costs of care remain distressingly high.…”

Healthcare Utilization of Complex Chronically Ill Children Managed by a Telehealth-Based Team

“…First, the presence of an outpatient complex care team which actively engaged with inpatient discharging teams may provide opportunities to identify and address barriers prior to discharge resulting in reduced hospital days. Programs focusing on discharging ventilator-dependent children (a large proportion of the FLIGHT population) have shown similar improvement on these metrics ( 23 ) as has a recent randomized control trial looking at inpatient consultation by outpatient complex care physicians ( 24 ). Furthermore, availability of a complex care team to continue to address elements of care initiated in the inpatient environment (e.g., referral to home nursing agencies) could have enhanced the discharging team and family's comfort in ensuring follow-up and attention to complex outpatient needs.…”

“…Attention to engaging these resources after discharge may have increased a family's capacity to remain at home and feel supported in doing so. This study builds on evidence from other studies that complex care coordination teams can decrease healthcare utilization (15,20,24). In contrast to other programs, our model emphasizes a consultative/co-management strategy and in particular, given our large geographic catchment area, utilizes a telehealth care delivery system almost exclusively for its outpatient follow-up.…”