March, 2015

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A comprehensive approach to caring for hospitalized medically

complex patients

Ndidi Unaka, MDChristine White MD, MAT

Cincinnati Children’s Hospital Medical Center

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Objectives

• Highlight importance of coordination in caring for medically complex patients

• Describe strategies for providing hospitalized medically complex patients comprehensive care

• Identify barriers/corresponding solutions to developing comprehensive care team models

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Complex Care Patient4 year old male with chromosomal disorder

• Severe neurologic impairment• Hydrocephalus s/p Ventriculoperitoneal shunt• Epilepsy (on multiple antiepileptic drugs)• GT dependent (s/p Nissen)• Cleft lip and palate s/p repair• Chronic respiratory failure (tracheostomy and BiPAP dependent)• Hypothyroidism• Spasticity

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Specialists Involved• Complex Care Center• Neurology• GI• ENT• Pulmonary• Physical Medicine & Rehab• Plastic Surgery• Endocrinology

Utilization• 7 medical admissions in last

year• 50 inpatient days• 5 ICU bed days• Average of 3 consults/admit• Average of 25 discharge

medications

Complex Care Patient

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Definition: Children with Complex Medical Needs• Children with complex medical needs rapidly growing

population• Group includes children with:

– A clearly identified medical specialty home – Neurologic impairment – Technology dependence

Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. Mar 2011;127(3):529-538.Berry JG, Hall M, Hall DE, et al. Inpatient Growth and Resource Use in 28 Children's Hospitals: A Longitudinal, Multi-institutional Study. Arch. Pediatr. Adolesc. Med. Dec 24 2012:1-9.

Definition

Gastrostomy tube

Tracheostomy tube

Neurologic impairment (ex: cerebral palsy, brain injury)

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At Risk Population

• High utilization of hospital resources• Increasing admissions• At risk for medication errors• Limited longitudinal handoff between

inpatient and outpatient providers

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Our History

2011 2013

Complex patients distributed amongst all 5 HM teams Creation of New

Complex Care Team

Remainder of neurologically impaired and technology dependent patients distributed among other 4 HM teams

-Staffed by HM attendings (350 pts/year)

-Patients from Complex Care clinic designated to one HM team

-Staffed by Complex Care Clinic attending (105 patients/year)

-Other general HM patients also on team

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Complex Care Team• Created to provide specialized care to this unique

patient population• All patients who are neurologically impaired or

technology dependent admitted onto 1 HM team, including

• Complex Care Clinic patients• Palliative Care patients• Transition Adult Care Patients

• Maximum 9 Patients

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Rationale for the Creation of an Inpatient Medical Home • Improve care coordination• Provide more family centered care• Improve the safety of this high risk population• Develop a core group of HM attendings with expertise

and investment in caring for patients with complex medical needs

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Multidisciplinary Rounds

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• Specific Care coordination rounds once/week

• Medication reconciliation rounds 2x/week

• Multidisciplinary verbal attending handoff each Friday with outpatient providers

Care Coordination/Safety

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Family-Centered Care

• Very positive feedback from families:– “I feel like things get done faster now”

– “Yellow team has been the best thing that happened to my daughter since we have been here”

– “You guys said you talked to my pediatricians in complex care clinic and the rehabilitation physicians but I didn’t believe it until I saw you in rounds together. This makes me feel great”

– “Is discharge always this easy?”

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Outcomes: Discharge EfficiencyPrior Work

Physicians define

medical criteria in EHR on

admission

Patient meets

medically-ready criteria

Nurse places time stamp in

EHR

Goal to leave within 2 hours of

meeting all criteria

• Patient-focused around disease process improvement• Do not aim for an arbitrary time of day

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Frontline Staff Engagement 

Consult Timeliness

Pharmacy Process Change

How will this process apply to complex patients

with unique discharge needs?

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SMART Aim

Increase the percentage of medically complex pediatric patients discharged within 2 hours* of meeting medically ready criteria from 50% to

80% by September 1, 2014

*If criteria were met between 8:00pm – 7:00am, patients were not expected to leave until 9am

Key Drivers

Increase the percentage of

medically complex pediatric patients

discharged within 2 hours of meeting medically ready

criteria from 50% to 80% by

September 1, 2014

Anticipation of Discharge Care Needs

Staff Engagement in Discharge Preparedness

Care Coordination

Optimization of Team Structure

Discharge Goal Identification

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Run Chart

Cohort Patients on Complex

Care Team

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Run Chart

Cohort Patients on Complex

Care Team

Creation of Complex Care

Admission Order Set

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Complex Care Order Set

© 2013 Epic Systems Corporation. Used with permission.

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Weekly Multidisciplinary

Care Coordination

Rounds

Medication Pathway

Needs Assessment Tool and Reminders

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Needs Assessment Tool

• Equipment• Home Health Care

Needs • Private Duty Nursing• Transportation

• Medications• Follow-up

Appointments• Social/Family

Concerns• Education Needs

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Run Chart

Weekly Multidisciplinary

Care Coordination Rounds

Needs Assessment

Tool and Reminders

Medication Pathway

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Future Directions

• Adapt and improve current processes in place• Developing communication tools for families and

clinicians across the continuum of care• Tools for while kids are hospitalized AND in the

transition home

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Barriers

• Lack of ancillary support• Institutional buy in

• Financial support• Faculty, resident, and nursing comfort with

caring for patients with complex medical needs• Time• Lack of outpatient and subspecialty partners

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Strategies

• The ideal?– Define the role of the primary care physician

• Rounds on the first day of admission in which the PMD and hospitalist are both present

– Optimize the role of subspecialists• Integration of primary subspecialists’ thoughts into the

plan of care

– Provide support for families during long hospitalizations and transitions of care

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Resident Curriculum• Trach/G-Tube Practical Discussion• DNR/DNI/Hospice• General approach to patient with special needs• A Day in the Life of a Special Needs Parent• Common Overnight Mommy Calls/Emergencies • Nutritional Concerns in Special Needs patients• Management of Patients with Cerebral Palsy• Autonomic Storming• Ethics/Month-End Debrief

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Secondary Outcomes

• Median LOS: 3.1 days to 2.2 days (p = .13)

• Readmission rates: 31% to 22% (p = .23)