Programs for Children with Complex Chronic Conditions at Brenner Children’s Hospital Savithri Nageswaran MD,MPH September 12 th 2012
Mar 31, 2015
Programs for Children with Complex Chronic Conditions at Brenner
Children’s HospitalSavithri Nageswaran MD,MPH
September 12th 2012
PEDIATRIC ENHANCED CARE PROGRAM
• Pediatric Enhanced Care Team (PECT)• Community Pediatric Enhanced Care Team
(CPECT)• Community Pediatric Enhanced Care Team
(CPECT-Extend)• Collaborative Care Service
Medical Neighborhood:Healthy Child
Child & Family
AHRQ White Paper: Medical Neighborhood
Medical Neighborhood:Child with a Chronic Condition
Child & Family
AHRQ White Paper: Medical Neighborhood
Medical Neighborhood:Child with Complex Chronic Condition
Child & Family
AHRQ White Paper: Medical Neighborhood
Pediatric Enhanced Care Program• PECT: pediatric palliative care in the hospital for seriously ill children
– 1 FTE nurse & 0.3 FTE physician– Funding: Duke Endowment start-up funds; now Brenner Children’s
Hospital• CPECT: care coordination for children with CCC in Forsyth County
– 0.5 FTE nurse, 0.05 FTE project director, 0.1 research associate– Funding: Maternal & Child Health Bureau
• CPECT-Extend: Extension of CPECT to Yadkin, Surry, Stokes, Davie, Wilkes counties– 0.75 social worker, 0.05 project director & 0.1 research associate– Funding: Maternal & Child Health Bureau
• Collaborative Care Service (CCS): collaboration between multiple sub-specialists in the care of children with undiagnosed complex conditions– 0.5 FTE nurse & 0.15 physician– Funding: Brenner Children’s Hospital
Children with CCC at Brenner Children’s Hospital(FY 2009 PECT Patient Statistics)
Medical Center Strategic Planning; January 2010
Children with CCC at Brenner Children’s Hospital(FY 2009 PECT Patient Statistics)
Utilization PECT (%)*3-Day Readmission Rate 6.9 %
7-Day Readmission Rate 11.9 %
14- Day Readmission Rate 21.1 %
30- Day Readmission Rate35.6 %
ED Visits within 7-days of Discharge
1812%
*Medical Center Strategic Planning; January 2010
Children Enrolled in CPECT & CPECT/E (n=56)
• All <18 (one now older than 18)• All chronic condition• Complexity upon enrollment– >5 subspecialists/services 46 yes, 4 no, 2 missing– >2 technology 29 yes, 19 no, 4 missing– >3 hospitalization/months 14 yes, 34 no, 4 missing– >30 days hospitalized/6 months 20 yes, 28 no, 4
missing
Care Coordination Needs
Child & Family
Medical Home
Specialist
Dentist
Pharmacy
Care Coordination Needs:Complexity
Child & Family
Care Coordination Needs:Low Fragmentation
Child & Family
Care Coordination Needs:High Fragmentation
Child & Family
Care Coordination Needs: Family Capacity
Care Coordinator's Contacts with Children with CCC & their Families
Care Coordination of Children with CCC
Gaps in Coordinated Care of Children with CCC
Community Team to Coordinate Care of Children with CCC
Community Team to Coordinate Care of Children with CCC
Community Team to Coordinate Care of Children with CCC
Community Team to Coordinate Care of Children with CCC
Community Team to Coordinate Care of Children with CCC
PEDIATRIC ENHANCED CARE PROGRAM
• Pediatric Enhanced Care Team (PECT)• Community Pediatric Enhanced Care Team
(CPECT)• Community Pediatric Enhanced Care Team
(CPECT-Extend)• Collaborative Care Service• New: Interdisciplinary clinic for children with
CCC