Spanning the Continuum of CareChuck Willson MD

September 13, 2012

Give you a snap shot of what we have accomplished over the past six years

Not get bogged down in details Give details in response to questions

No disclosures

A subset of Children and Youth with Special Healthcare Needs (CYSHCN)

Children who don’t fit into a specialty clinic care model (not Heme/Onc, not GI, not Nephro, etc)

Our kids have chronic respiratory disease, chronic neurologic issues, and often require technology to survive and home nursing to live at home

Often starts in the NICU or PICU Transitional Care Unit (TCU) is a six bed

ventilator- capable unit to prepare for discharge

C5 clinic: a referral clinic to evaluate children with complex and chronic conditions on referral and to follow kids who leave the TCU

Primary Care Medical Home: inform and coordinate care in the home community

40% of primary care docs had no ongoing training in caring for CYSHCN since residency

78% said they did not have the time, resources or knowledge to care for CYSHCN

95% wanted additional CME opportunities in caring for CYSHCN

52% could not easily transition their CYSHCN to adult practices

28 families surveyed at 4 community forums

34% felt respected by the medical staff 50% felt that the doc listened to their

concerns 5% had written care plans

Physicians: Dr Strope (Pulmonologist), Drs Willson and Crotty (Ped Generalists), Dr O’Keefe (Ped Hospitalist), Dr Brake (Med-Peds)

Hospital Administrator: Matthew Robertson Nurse Practitioner: Kate Gitzinger RN, PNP Care Coordinators: Kathy Watson (RN),

Courtney Johnston (Child-Life), Tierrany (RT), Rhonda Stanley (SW)

3331

41

0

5

10

15

20

25

30

35

40

45

2008 2009 2010

AL

OS

in

Da

ys

Year

33%

29%

21%

0%

5%

10%

15%

20%

25%

30%

35%

2008 2009 2010

Year

% o

f R

e-A

dmits

73%67%

54%

0%

10%

20%

30%

40%

50%

60%

70%

80%

2008 2009 2010

Year

% o

f R

e-A

dmits

252

71

113

63

0

50

100

150

200

250

300

ED visits Hospitalizations

Before After

11% Reduction in Visits after C5 Intervention

55% Reduction in Hospitalizations after C5 Intervention

Reduction in Visits/Stays

Average Total Cost Per Visit / Inpatient Stay

Overall Total Cost Avoidance

ED Visits: 8 $515 $4,120

Hospitalizations: 139 $47,277 $6,571,503

Total program cost avoidance from 10/1/2008 thru 12/31/2010 = $6,575,623

Train our medical students and residents in the care of children with complex conditions and their families

Reach out to the primary care medical homes of our patients and strengthen ties

Develop a similar system of care for adults with complex childhood conditions (CACCC)

We need to better address the needs of this growing population

Patients and parents benefit from a continuum of care and from care coordination

We need to increase the comfort level of new providers and help them see beyond hospital walls

The C5 model demonstrated improved patient outcomes