Pediatric Complex Care Management

Pediatric Complex Care

Management

Kristen Foose RN, BSN, CPN

Objectives

–gain an understanding of the impact that pediatric care management has had on the patients, families and healthcare providers. –be able to describe the benefits of care coordination and the

importance with complex children.

–gain an understanding of what outpatient care managers do and their importance.

–be able to identify the gaps in healthcare prior to care management.

Disclosure of Conflict

I have no relevant financial relationships with the manufacturer(s) of any commercial products(s) and/or provider of commercial services in the CME activity.

I do not intend to discuss commercial products or services and unapproved/investigative uses of a commercial product/device in my presentation.

OSF HealthCare System

Acute care hospitals 11

Heart hospital 1

Children’s hospital 1 OSF Medical Group locations 75 OSF Locations not including hospital 108 Clinic site locations 193 Prompt care sites 13

OSF HealthCare System

Employs more than 667 physicians and mid-level providers operating in eight LLC corporations and in more than 80 office sites

OSF HealthCare owns an extensive network of home health services known as OSF Home Care Services and also owns OSF Saint Francis, Inc., comprised of healthcare-related businesses, and OSF Healthcare Foundation, the philanthropic arm for OSF Healthcare System and OSF Home Care Services

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The Communities We Serve

OSF Saint Anthony’s Health Center Other OSF HealthCare Facilities

OSF Mission

In the spirit of Christ and the example of Francis of Assisi, the Mission of OSF HealthCare is to serve persons with the greatest of care and love in a community that celebrates the gift of life.

OSF Vision

Embracing God's great gift of life, we are one OSF Ministry transforming health care to improve the lives of those we serve.

Every patient, every person, every time.

Care Transformation Advisory Committee

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History of Care Management

Expanded into two other offices in 2012 and additional pediatric care manager hired

Now in several offices and regions with a total of five RN care managers, one social worker and two health coaches and continuing to expand

Care Management Team Focus Statement

The Care Management Team promises to foster and

support the OSF Mission by using an interdisciplinary team approach to help patients and their families achieve the highest possible functioning levels so they can be part of their communities. We will foster and support each other by challenging and encouraging our co-workers to use their individual, unique strengths, skills and talents to build a cohesive team to care for our patients. This is a shared commitment to transforming health care as a culture that cares.

Why Care Management?

Fragmented healthcare system

System is hard for parents to navigate

Lack of communication

Barriers to coordinating care

Difficulty with transitioning care

Alex’s story

Care Management

Planning and coordinating the physical, mental, and social needs of a patient to help improve their health and maintain their independence

This entails managing, referring, and coordinating health and social services

Team approach

Team consists of –Care Manager –Social Worker –Health Coach

Complex Care Managers

–Qualifications

• Bachelor’s of Science in Nursing (BSN) degree required • Registered Nurse with an Associate’s degree will be required to

complete a BSN within 5 years of hire date with completion of such requirements no later than 2020

• Three to five years of experience caring for patients with progressively increasing responsibility

• Care Management certification as appropriate for adult or pediatric within 3 years of hire.

Complex Care Manager

A Complex Care Manager is a health care provider, typically a nurse, who works as a member of the patient’s care team, providing holistic, longitudinal care to a panel of patients

Care Managers are advocates who help patients/parents understand their current health status, what they can do about it and why those treatments are important

Complex Care Manager

Guide patients/parents and provide cohesion to other professionals in the health care delivery team, enabling their clients to achieve goals more effectively and efficiently

Work together with and the primary care physician to assist in the care of the patient

Assess, plans, implements, coordinates, monitors, evaluates interventions and develops a comprehensive plan of care for each patient

Complex Care Manager

Assess medical/social needs

Educate and engage

Support

Smooth transition of care

Patient advocate

Create care plan

Proactive monitoring of patient

Accessing community services

Communicate with all involved

Close follow up

Transitions

Social Worker

–Bachelor’s degree in Social Work from a school or program accredited by the Council on Social Work Education is required; Master’s degree in Social Work preferred

–Will obtain a license for social worker degree with in three years –Care Management certification as appropriate for adult or pediatric

within 3 years of hire

Social Worker

Responsible for identifying, assessing, planning, coordinating, implementing, monitoring and evaluating options and services across the continuum of care for individuals in assigned case load

Health care services are coordinated on behalf of the patient to promote the delivery of care at the appropriate level of care which will optimize clinical outcomes and satisfaction with services

Social Worker

Addresses both the patients bio psychosocial status as well as the state of the social system in which care management operates

Develops and maintains a therapeutic relationship with the client

Assists the patient's with systems that provide services, resources, and opportunities

Co-manages patients with the Complex Care Manager if patient has both social and medical needs

Heath Coach

Qualifications:

–Associate’s degree in health education, health promotion or equivalent

–Two years of experience in clinical, counseling or health care setting caring for patients with chronic, complex illnesses (adult experience for adult and pediatric experience for pediatric) adult and/or pediatric care management experience preferred. Broad knowledge of chronic illness and medical and community resources required

Health Coach

–Complex Care Manager manages new patients for a minimum of 90 days, and if stable will then transition to the health coach

Promote disease management, preventative care and wellness

Coordinates, monitors, and follows up with patient to ensure patient they are working toward the comprehensive plan of care and care goals

Performs ongoing communication and works to promote quality of

care COMMUNICATING

MONITORING

FOLLOW-UP CONNECTING COORDINATING

Care Management

Helping patients manage their health, maintain their independence and improve their quality of life

Managing, referring and coordinating health and social services

connecting to community resources

Monitoring

Monitor and keep tract of appointments and testing

Ensure that patients get seen with their PCP if sick for continuity of care

Monitor immunizations and preventative testing to ensure that they are completed

Follow-up

Weekly calls on new patients for one month

Monthly check in calls/care plan updates

Connecting

Advocate for patient and assist them in getting the services they need

Answer questions and help explain what is going on and why things are needed

Discuss services and resources

Assist in transition issues

Coordinating

Coordinate coverage with insurances

Coordinate referrals

Coordinate with home health/home nursing

Facilitate coordination between physicians and specialists

Coordinate all appointments and testing

Communicating

Communicate the needs of the patient to all that are involved

Care plan is accessible to all specialists, hospital staff and parents to ensure continuity of care

Collaborate and ensure that all specialists notes are received

Ensure that the parents are receiving the communication they need to care for their child

Communicate the plan of care

It is the simple things…

Referral Process

Predictive risk assessment tool

Hospital referral

New Enrollment

Intake process:

–Meet with parent/patient in person or complete over the phone –Discuss

Arrival needs Challenges Goals

Diet Equipment School

Specialists Dentist Risks

Therapies Living situation MyHealth

Community Resources

New Enrollment

Weekly calls for a month

Monthly calls for updates

Care plan updates monthly, sooner if any new changes

Care Plan

Individualized care plan established for each patient.

Goals are identified

Needs are identified

Care plan is shared with patient

Care plan is able to be viewed by all (outpatient/inpatient)

Updated monthly or as needed

Care Plan

–Challenges/barriers –If something goes wrong –To do

Care manager’s action items

Diet/nutrition

Current medications

Care team

Upcoming health maintenance

Care managers impressions

Hospital Admissions

Receive notification if a care managed patient is hospitalized

Utilize and communicate with case management in the hospital

Will attend care conferences if appropriate

Hospital Discharges

Receive a hand off when patient is discharged from the inpatient case manager

Follow up call done with in 24 hours of discharge

Work weekend and holiday hours to be able to follow up on discharges in a timely manner

–Medication reconciliation –Follow up appointments –Address needs and concerns –Assure all equipment delivered

Payton

Costello syndrome

Transitional cell carcinoma of the bladder

Currently 15 years old

Payton

Transitioning to adult care

Begin discussion of transitioning between 12-14 years of age

Develop transition plan of care

Work with adult care manager and transition patients to them

MD to MD hand off

Social worker plays a large part in the transition process in assisting with guardianship, insurance etc.

Transition plan

– Adult primary care – Adult specialty care – Adult dental care – Schedule doctor appointments – Refill my medications/supplies – Know my medications/treatments

and why I take them – Describe my medical condition and

understand the disease process and hoe to manage the disease – Describe and understand my

specific diet

– Consent for medical care – Guardianship options – Plan for education – Plan for employment/work – Plan for independent living – Plan for transportation – Plan for finances/money

management – Paying for medical care – SSI

– Financial decisions

Parent/patient testimonies

I do not have to repeat myself and tell the long history of my son each and every

time I call the office. Care is streamlined and my care manager understands and knows what is going on and can get us the help that we need.

You have helped us think through sticky situations and assist us in solving the

situation.

You have been our rock, and helped us through the hardest time of our life. You

supported, advocated and assisted us through so much. You are very valuable and we appreciate your services more than you will ever know.

You get to the meat of the problem. I do not need to spend 15 minutes

explaining what the history of my child is before we get to the problem. This is very valuable.

You are like a Walmart, one stop shopping, you have and know it all about our

son. You bring the team together, organize and prioritize and help me when I am crashing and need to talk.

You make my life easier, period.

Provider testimonies

I am able to have a knowledgeable, go to person who understands the patient and can assist in times of need.

You are my go to person for everything for the care managed kids.

You are easy to get a hold of and you know exactly what is going on with all the kids, otherwise I am calling random nurses that do not understand complex kids.

Central contact for families, patients, and other providers to communicate needs with.

You know and understand the complexity of the child.

Referrals, therapies, and appointments are easier and can be done through you.

You have the flexibility to meet families at non standard times and can even come to the hospital.

Much more thorough explanations of testing and results, very valuable to the parents and patients.

Questions

Resources

Evans, M. (2015). Demand grows for care coordinators. Health Services

Administration. 45 (13).

Kelleher, K., Cooper, J., Deans, K., Carr, P., Brilli, R., Allen, S., Gardner, W. (2015).Cost saving and quality of care in a pediatric accountable care organization.

Pediatrics. 135 (3).

Taitsman, D. (2015). Medicaid managed-care patients face hurdles in getting care.

Modern Healthcare. 45 (1).

Venegas, M., Zubarew, T., Pacheco, F., Besoain, C., Paula, V., Velarde, M..Reinoso, A. (2015). 244. The transition process from pediatric to adult services: perspectives from adolescents with chronic diseases. Journal of adolescent health. 56 (2).

Wong, C., Chan, F., Wong, F., Wong, E., Huen, K., Yeoh, E., Fok, T. Transition care for adolescents and families with chronic illnesses. Journal of Adolescent Health. 47 (6).