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