Complex Care Does Not Have to Equal Complex Transitions: How to Help Make Transitions Smoother

GWENN LARAGIONE, RN, BSN, CCM, CHPPN

BARBARA S ZIMMARO MSN, CRNP, CNPN

This lecture has no commercial support to disclose

Gwenn LaRagione and Barbara S Zimmaro have no relevant financial relationships to disclose

Objectives

Identify at least three core principles in assessing the needs of a medically complex pediatric patient during transitions in care.

Describe the importance in identifying the stakeholders involved during a transition of a medically complex pediatric patient. 

Identify at least three steps in the planning process of coordinating a transition of a medically complex pediatric patient.

Describe the challenges and rewards experienced in transitioning a medically complex pediatric patient.

Medically Complex Children

Children with: intense medical needs multisystem disease states complex medication regimens

Journal of American Academy of Pediatrics

Increasing Prevalence of Medically Complex Children in US Hospitals

Katherine H. Burns, MD, Patrick H. Casey, MD, Robert E. Lyle, MD,

T. Mac Bird, MS, Jill J. Fussell, MD, James M. Robbins, PhD, 2010

NHPCO Web site

Concurrent Care

On March 23, 2010, President Obama signed the Patient Protection and Affordable Care Act into Law, with a new provision, Section 2302, termed the “Concurrent Care for Children” Requirement.

Concurrent Care

“A voluntary election of hospice care for a child cannot constitute a waiver of the child’s right to be provided with, or have payment made for, services that are related to the treatment of the child’s condition, for which a diagnosis of terminal illness has been made.”

Medically Complex Children

Multiple specialists/providers Medical equipment providers Home Care Agencies Advocacy groups/agencies Transition across various health care and

community settings More than one payer Complex care coordination

Pediatric Care Coordination… ….is a patient-and family-centered,

assessment-driven, team-based activity designed to meet the needs of children and youth while enhancing the care giving capabilities of the families. Care coordination addresses interrelated medical, social, developmental, behavioral, educational and financial needs to achieve optimal health and wellness outcomes.

Policy Statement: Patient-and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems; From the American Academy of Pediatrics, 2015

Care Coordination

Is paramount in developing and fostering partnerships across various settings and communities

Enables the achievement of the triple aim:

-Better Care

-Better Health

-Lower Cost

Policy Statement: Patient-and Family-Centered Care Coordination: A Framework for Integrating Care for Children and Youth Across Multiple Systems; From the American Academy of Pediatrics, 2015

Patient- and Family-Centered CareAmerican Academy of Pediatrics

Family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in mutually beneficial partnerships among health care providers, patients, and families.

Family-centered care is a respectful family/professional partnership that honors the strengths, cultures, traditions, and expertise that everyone brings to the relationship. Family-centered care is the standard of practice which results in high quality services

Core Principles of Patient and Family-Centered Care

AAP – 1/2012

Listening and respecting the child and family Ensure flexibility Sharing complete, honest and unbiased

information Providing and/or ensuring formal and

informal support Collaboration with patients and families at

all levels of health care Recognizing and building on the strengths of

individual children and families

Change in medical condition Change in location Change in caregivers Change in goals

Times of Transition

What is the central issue?

Why is a change needed?

Who are the stakeholders?

When: Timeline/Venue(s)?

What are the steps needed to accomplish the goal?

Stakeholders:

Child Family

Medical Team

Nursing Agency

LTC facility

Hospice

Local Hospital

School District

EMSTranspo

rtFaith

communityExtended

Family/Friends

Pre-meeting of primary stakeholders (face to face or conference call)

Describe anticipated changes and walk-through possible outcomes

Explicitly name the person responsible for each task

Checklists Anticipate imperfection Plan for ongoing, regular

communication

Planning…and more planning!

Checklists

Patient/Family Discussions-Who’s the decision maker-What are the goals of care-What other family members should be

included in discussions -Identify ongoing communication

schedule -Identify the best way/time to reach

decision maker

Checklist

Initial Tasks-Initiate referrals-Arrange meet and greets; schedule

tours-Notify primary pediatrician and

specialists-Determine date/time of transfer-Confirm correct address (home, facility)-Notify payer/s; obtain authorizations-Schedule transport-Complete admission forms prior to

discharge if possible

Checklist

Medications-Review patients medications and schedule

-Are there any compound meds

-What medications does the patient already have,

what scripts are needed

-Who will be providing the medications

-Do any medications need prior authorization

-Have all medications filled prior to transport

-IV medications

Checklist

Medical Equipment -Are they reproducible in the home/facility

-Identify what is already in the home and make sure it’s in working condition; is there enough oxygen

-Does home need an inspection for electricity

-Have equipment delivered and set up prior to

discharge

-Is back up equipment needed

Checklist

Prior to Discharge- Complete admission forms (home care,

hospice, facility, etc) prior to discharge/transfer

- Complete DNR/POLST forms if applicable

- Develop individualized plan of care with participation of patient/family/providers

- Identify an ongoing communication schedule

Checklist

Preparing the Patient/Family-For the transition

-For the uncertainties

-Arrange a discharge/transfer family meeting

Checklist

Psychosocial Support -Access need for spiritual support

-Access need for sibling support

-Offer memory making/legacy activities

-Offer bereavement support

-Determine if family informed extended family

of the plan

Checklist

Sign-out - Physician to Physician

- Nurse to Nurse

- Social worker to Social worker

- Chaplain to Chaplian

Transitioning off Hospice

Celebrate!!!!! Give plenty of notice Notify primary physician Notify specialists Transition payer for DME or switch to a contracted

provider Transition scripts to a retail pharmacy Check what co-pays will be Constant communication

Challenges

Complex coordination

Financial Resources

Physical Space

Language

Cultural awareness

Time!

Rewards The best in family and child

centered care

Provides meaningful roles for invested stakeholders

Enables the achievement of the triple aim:

-Better Care

-Better Health

-Lower Cost