Abstract
Background:
The prevalence of chronic disease among American children has increased as a result of decreased mortality from once-fatal diseases. Pediatric healthcare providers must be prepared to tend to an increasing number of children with special healthcare needs (CSHCN). Doctors in training are often not well versed in the care of CSHCN nor do they receive training in advocacy or care coordination, yet the patients they see in continuity clinic are likely to be underrepresented minorities who are uninsured or publicly insured and less likely to have access to care management. Our project goal was to study the influence of team-based comprehensive healthcare coordination on outcomes for children with complex healthcare needs in a pediatric resident continuity clinic.
Methods:
We enrolled 27 patients. Interventions included a 1-hour initial visit, 40-minute follow-up visits with face-to-face time with all team members, telephone access directly to the social worker, and follow-up scheduling during office visits. A care coordination binder was provided to each patient, and monthly team meetings were held to discuss enrolled patients. The study period lasted 12 months. Data were collected for the time period 12 months prior to the initiation of the study. Data collected included completed and no-show visits for primary care and subspecialty appointments, hospitalizations and ED visits, continuity of care, use of care-coordination binders and medications, and results from parent satisfaction surveys that were administered every 3 months.
Results:
Patient satisfaction and perceived quality of life showed no significant change between baseline and postsurvey. The no-show rate at the continuity clinic showed no significant difference overall, although patients with a CSHCN screener score of ≥4 were 5.3 times more likely to keep the appointment (P = 0.01). The number of missed appointments decreased from 26% to 24%. Continuity showed a significant increase, the number of hospitalizations decreased from 4 to 2, and the number of ED/urgent care visits decreased from 40 to 26.
Conclusion:
Our project successfully decreased costs. We found that continuity with the PCP played a key role in developing relationships, connecting patients with critical resources, and instilling in residents a sense of confidence and self-efficacy. Future implementation and study will require recruiting a larger number of patients, investigating which subgroups benefit more from care management programs, and integrating our process across all resident panels to promote study generalizability, improve continuity and care team collaboration, and foster resident education and a desire to care for CSHCN in residents’ future practices.
PROJECT MANAGEMENT PLAN – The Influence of Comprehensive Care Coordination on Patients with Chronic Medical Conditions and Special Healthcare Needs in a Community Pediatric Residency Program Continuity Clinic.
| Vision Statement | Our vision is to educate, motivate, and empower vulnerable patients and young physicians by clarifying the roles of existing resources, streamlining communication among stakeholders, and utilizing a team-based strategy to deliver excellent care. |
| Team Objectives | Our objectives were as follows:
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| Success Factors | The most successful parts of our work were as follows:
We were inspired by the commitment of the parents of our patients and their ability to overcome barriers with our help and also the commitment of the residents to their patients despite busy work schedules. |
| Barriers | The largest barriers encountered were research issues: families often did not bring their binder to the office visit and some data were difficult to obtain/track (eg, medication compliance). Family issues such as instability of living situation, lack of transportation, and limited access to telephones were also barriers. Finally, researcher issues such as residents’ schedules being affected by work duty hours and their panels having a limited number of spaces each clinic day were other barriers. We worked to overcome this challenge by increased access to care with direct social work contact and regularly scheduled appointments with the care team and by regularly reassessing patient needs with patient care team meetings. |
| Lessons Learned | The single most important piece of advice to provide another team embarking on a similar initiative is to make sure resident continuity is the highest priority for children with special healthcare needs in the residency clinic setting, utilizing whatever resources the clinic has available to make this happen (schedulers, dedicated RN coordination, etc.). This continuity has improved the team’s ability to build relationships and their ability to care for the patients. Also, follow strict protocols throughout the entire research process and meet regularly to discuss the protocol itself. More advice is as follows:
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