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Pediatric Care Coordination CurriculumMODULE 1
Richard Antonelli, MD, MS, FAAPRenee Turchi, MD, MPH, FAAPKathleen Huth, MD, FRCPC, MMSc-Medical Education
Module 1
Module 2
Module 3
Module 4
Module 5
Antonelli R, Huth K, Rosenberg H, Bach A. Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in achieving Optimal Child Health Outcomes, 2nd Edition. Boston Children’s Hospital, 2019.
Antonelli R, Turchi R, Huth K. Module 1, High Value-Integrated Care Outcomes Depend on Care Coordination. In Antonelli R, et al, Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in achieving Optimal Child Health Outcomes, 2nd Edition. Boston Children’s Hospital, 2019.
The development of the Pediatric Care Coordination Curriculum: An Interprofessional Resource to Effectively Engage Patients and Families in Achieving Optimal Child Health Outcomes, 2nd Edition is supported through a sub-contract with the National Center for Medical Home Implementation (NCMHI), a cooperative agreement with the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS). The information or content are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by MCHB, HRSA, HHS or the U.S. Government.
High-Value Integrated Care Outcomes Depend on Care Coordination
2 » Module Overview
3 » Introduction
4 » Facilitator Guide–Slide Deck
24 » Case-Based Learning
© 2019 Boston Children’s Hospital. All rights reserved.
Module 1Pediatric Care Coordination Curriculum 2nd Edition 1© 2019 Boston Children’s Hospital.
All rights reserved.
High-Value Integrated Care Outcomes Depend on Care Coordination
Module 1—ObjectivesAt the end of this session, participants should be able to:
• Discusskeycomponentsofcarecoordinationwithinanintegratedmodelofcaredelivery.
• Assesscurrentpracticesthatsupportcarecoordinationandintegratedcaredeliveryinavarietyofsettingsincludingstate,regional,deliverysystem,communityagencies,orclinics.
• Prioritizeareasofimprovementincareintegrationandcarecoordinationintheircurrentpractice.
• Identifyestablishedtoolsandprocessesthatcanbeusedtoimplementkeycomponentsofcarecoordination.
• Developanactionplanoutliningspecificgoalstofacilitatecarecoordinationintheirpractice.
Note to the facilitator:
Pleasebeawarethatwhenimplementingthismodule,itiscrucialtoincludelocal-,state-,andregion-specificcontent.
A foundinthemoduleindicatestheneedforlocalcontenttobeadded, butfacilitatorsshouldfeelfreetoincludelocalcontentwherevertheyseefit. Localcontentincludes,butisnotlimitedto,thefollowing:
• Culturalaspectsofthecommunity(includingassets,vulnerabilities, and language)
• Sociodemographicfactors• Geography• Local,state,and/orregionalresources
Thereare2tablesincludedbelow.Thefirstisahigh-levelagendaofthemodule.Thesecond is the facilitator guide that includes a breakdown of slide content and talking points.Thefacilitatorshouldusetheguideasaresourcetotailorthetraining.
Thecurriculumisintendedtobetailoredtofitthetrainingneeds,andthecontent canbemodifiedfordifferentaudiences.Therefore,contentfromthismodulecanbeselectedandincorporatedintothetailoredtraining.However,asuggestedagenda forimplementingthismoduleasastand-aloneisincluded.
Module 1Pediatric Care Coordination Curriculum 2nd Edition 2
Pre-sessionreading
Introduction
Didactic: care coordination fromtheoryto practice
Teamactivity:asset and needs assessment
Casestudy:KeystonePediatrics
Shared plan of care
Action-oriented exercise: SMART goals
Closing/summary
N/A
5min
15min
20min
35min
25min
15min
5min
Can be found at: https://jamanetwork.com/journals/jamapediatrics/article-abstract/2716802
Createtheslidedeckusingcontentfromthedidacticportion.Makesurethereisopportunity forparticipantstospeak.
Addlocalcontenttotheslidesasneeded.
Distributethehandouttoteamsorindividualparticipantsasappropriate.Giveparticipants 5minutestodotheassetsandneedsassessment asateam(ifapplicable).
Ask the learners to reflect on their current activities,thenaskforsome“headlines”tobe sharedinthelargergroup.
Giveparticipantsanopportunitytopracticetheconceptsandtoolstheyhavelearnedduringthetraining.Casestudiescanbetailoredsothattheyarerelevanttotheaudience/population.
Createtheslidedeckusingcontentfromthedidacticportion.Makesurethereisopportunity forparticipantstospeak.
Addlocalcontenttotheslidesasneeded.
ReferparticipantstoAppendixBofthismodule formorein-depthinformationondevelopingthesharedplanofcare. Participantsshouldcompletetheworksheet,detailing next steps to take after the session, basedonworktheyhavedoneinthesession.
Agenda Item Time Materials Required Instruction/Notes
Table 1
© 2019 Boston Children’s Hospital. All rights reserved.
The Pediatric Care Coordination Curriculum is offered for educational purposes only and is not meant as a substitute for independent medical judgment or the advice of a qualified physician or health care professional. Users who choose to use information or recommendations made available by the Pediatric Care Coordination Curriculum do so at their own risk and should not rely on that information as professional medical advice or use it to replace any relationship with their physicians or other qualified health care professionals.
Ten Essential Characteristics of Care Coordination
N/A
Slides
Handouts,asneeded(The assets and needs assessment can be found in the facilitator guide Getting Started: Identifying and Prioritizing Opportunities for Implementing High-Performing Care Coordination)
Copiesofcasestudy, as needed
Slides
Copies of handout, as needed
N/A
Module Overview
Module 1Pediatric Care Coordination Curriculum 2nd Edition 3© 2019 Boston Children’s Hospital.
All rights reserved.
Introduction
Note from the authors
Thecontentincludedinthismoduleprovidesaframeworkforfacilitatorstoexplorehowcarecoordinationactivitiesservethedeliveryofintegratedhealthcarefor patientsmostvulnerabletocarefragmentation.Thegoalistoprovidepracticalguidanceforlearnerstobeabletoidentifyopportunitiesforimplementingcarecoordinationactivitiesintheirownpractices.Learnersmaybephysiciansornonphysiciancliniciansofalldisciplines,schoolorcommunitypartners,payers,agencies,orpatientsandfamilies—ensurethatallappropriateteammembersareincludedinthistrainingopportunity.
Generalprinciplesandrecommendationsforcarecoordinationgroundedintheliteraturearesharedinthismodule,whileenablingdiscussionofcontext-specificchallengesandareasforimprovement.Itisimportanttoembedlocalinformation,includingresourcesorcontacts,intothecontentofthismodule—thiswillmakethelearningexperiencemorevaluableandrelevant.Forexample,facilitatorsmayconsiderreachingouttocommunityearlyinterventionprograms,schooldistricts,behavioralhealthclinicians,TitleVorganizations,AmericanAcademyofPediatricschapters,andfamilyadvocacygroups,amongothers.Thereisawidebreadthofservicesusedbyfamiliesandchildrenwithspecialhealthcareneeds,someofwhicharelistedinAppendixAofthismodule.
Animportantaspectofthismoduleforunderstandingtherelevantexperiencesofparticipatingteamsistheassetsandneedsassessment.Whatdocareteamsdotofacilitatecaretransitionsintheirpractices?Howdotheyconnectpatientsandfamiliestocommunityresources?Thesequestionswillhelpguidefacilitatorsindeterminingthekeyfocuspointsandresourcestosharethroughoutthesession.
Followingaresomequestionstodebriefthelearnersaboutthepre-sessionreading:
• Whatessentialcharacteristicofcarecoordinationresonatedmostwithyourexperience?
• Wereanyoftheseassumptionsasurpriseorsomethingyoudidnotrealizewasanaspectofcarecoordination?
• Thinkofyourownteam.Whichofthesedoyoudoparticularlywell,andwhichhaveopportunityforimprovement?
Thesequestionswillbedelvedintofurtherthroughoutthismodule.
© 2019 Boston Children’s Hospital. All rights reserved.
Bemindfulthatthisactivitywillhaveoptimalimpactifitispresentedasaninterprofessionallearningevent,withpatientsandfamiliesasco-facultyandco-learners.Thismulti-stakeholderlearningeventisintendedtosetthefoundationforajointlycreated,sharedvisionforempoweringpatientsandfamiliestoimpactthequalityofthecareprocessesthatimpacttheiroutcomes.Tactically,acommonlanguageofexpectations,terms,andperformancemeasureswillbehighlighted,ultimatelyresultingincareteammembersunderstandingtheirrespectiverolesandresponsibilities.
SLIDE 1 » Title Slide
SLIDE 3 » Objectives
Module 1Pediatric Care Coordination Curriculum 2nd Edition 4
Afterparticipatinginthismodule,learnerswillbeabletoachievetheobjectivesincludedonthisslide.
SLIDE 2 » Educational Purpose Only–No Medical Advice
ThePediatricCareCoordinationCurriculumisofferedforeducationalpurposesonlyandisnotmeantasasubstituteforindependentmedicaljudgmentortheadviceofaqualifiedphysicianorhealthcareprofessional.UserswhochoosetouseinformationorrecommendationsmadeavailablebythePediatricCareCoordinationCurriculumdosoattheirownriskandshouldnotrelyonthatinformationasprofessionalmedicaladviceoruseittoreplaceanyrelationshipwiththeirphysiciansorotherqualifiedhealthcareprofessionals.
Facilitator Guide–Slide Deck
This slide is an overview of the activities that support the learning objectives.
SLIDE 4 » Overview
SLIDE 5 » Objective
SLIDE 6 » Care Coordination
SLIDE 7 » What is Care Coordination
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 5
Informthelearnersthatthesessionwillstartwithadiscussionaboutthekeycomponentsofcarecoordinationwithinanintegratedmodelofcaredelivery.Thediscussionwilldistinguishbetweencarecoordinationandcareintegrationandexplorehowtheyarerelated.
Explaintothelearnersthattoday’sportionofthetrainingsessionwillteachthemhowtotakecarecoordinationfroman“in-the-clouds”concepttoon-the-groundactionintheirpracticesandcommunities.
Care coordination is the set of activities in the space between visits, careteammembers,andhospitalstays.Examplesmayincludebookingappointments,followingupontestresults,andliaisingwithcommunityservices.
Metricsofcarecoordinationincludeassessmentsofcaretransitions (eg,informationhandoffs)andcareplanimplementation.
© 2019 Boston Children’s Hospital. All rights reserved.
Words matter!Itisessentialtoacknowledgethattheremaybe somevariationinterminology,butthefacilitatormustgetthegrouptocometoconsensusonhowtodefine,operationalize,andmeasureperformanceofcarecoordination,careintegration,casemanagement,etc.
Care planningisanactivityofcare coordination, and care coordination leads to care integration. Care coordination is a domainofthebroaderframeworkofcareintegrationandisnecessary—butinsufficient—toachieveintegration.Whencare isintegrated,familiesperceivecollaborationbetweencareteammembers.SeeAppendixBofthismoduleonhowtobuildasharedplanofcare.
Case managementiscommonlyconfusedwithcarecoordination andcareintegration.Casemanagementisaprocessthataddresses thehealthneedsofpatients.Ittendstobefocusedonalimitedset ofpredetermineddiseasesorconditionsandguidedbypotentialhealthcarecostsavings.Traditionally,casemanagementservices areprovidedinabenefitspackage,oftensupportedbyahealthplan ormanagedcareorganization.
SLIDE 8 » Care Coordination Enables Integrated Care
SLIDE 9 » Integrated Care Framework
SLIDE 10 » Who Is Involved in Care Coordination?
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 6
Thisistheframeworkforcareintegration,whichistherightsideofthecarefragmentationdcareintegrationdiagraminthepreviousslide.Thisframeworkisfoundationaltounderstandinghowvariousactivitiesofcarecoordination(eg,referraltocommunityresources orplanningforthefuture)supporttheoutcomesofcareintegration.
Further,itshouldbeemphasizedthatthisbroadlyinclusiveframeworkisdesignedtoincludekeypriorities(health,medical,nursing,social,behavioral, and educational aspects of health) for care coordination implementationbyaddressingwhatisimportanttofamilies,physicians,nonphysicianclinicians,andcommunityleaders.
Carecoordinationisamultidisciplinaryteamsport,andpatientsandfamiliesareessentialteammembers.
Askthelearnerswhethertheyhavetherightpeopleintheroomwhendiscussingcarecoordinationandtoconsiderallofthedifferenttypesofcareteammembersandsettings.AgenciesmightincludetheDepartmentofMentalHealth,theDepartmentofDevelopmentalServices,andtheDepartmentofChildrenandFamilies.
© 2019 Boston Children’s Hospital. All rights reserved.
Thisimageofonefamily’scaremapdepictsallthedifferent“loci” ofcare.Caremappingisanimportantactivityforframingcarecoordination.Itisaprocessthatguidesandsupportstheability offamiliesandcareteamprofessionalstoworktogethertoprioritizeneedsandachievethebestpossiblehealthoutcomes. Source: http://bostonchildrenshospital.org/integrated-care-program/care-mapping
ThecaremappingprocessisdiscussedinmoredetailinModule2 asaneffectiveandvaluabletoolforfamily-leddiscussionsofcarecoordinationneedsandgoals.
ThecaremapshownherewasdevelopedbyCristinLind,whoinventedthecaremap.
SLIDE 11 » One Family’s Care Map
SLIDE 12 » Impact of Care Fragmentation
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 7
Considertheimpactoffragmentedcare.Someexamplesareincluded onthisslide.
Presenteeismiswhenemployeesarephysicallypresentatworkbut notfullyfunctioning(eg,duetodistractionsorconcernsfortheirownhealth).
Caregiversofchildrenandyouthwithspecialhealthcareneeds(CYSHCN),particularlycaregiversofchildrenwithcomplexmedical andbehavioralhealthneeds,aremorelikelytoreducetheirtimeorresponsibilitiesatworkortoquit,whichcontributestotheirstress. Toimproveemployeejobattendanceandproductivity,suggestthat thelearnersinterfacewithemployersintheirregiontodetermine howcarecoordinationforCYSHCNimpactswork.
Promptthelearnerstoconsidertheimpactofcarefragmentationonpatientswithbehavioralhealthneeds:86%offamiliesaresingularlyresponsibleforcoordinatingcareformentalandbehavioralhealthservices(Pondetal.,2012).
Familyexperiencewithcoordinatingcarefortheirchildrenand youthwithbehavioralhealthneedsdemonstratesthatthispopulation 4isespeciallyvulnerabletocarethatisfragmented,leadingtosignificantstressorsuponfamilies.
© 2019 Boston Children’s Hospital. All rights reserved.
Carecoordinationisadomainofthebroaderframeworkofcareintegration.Metricsofcarecoordinationincludeassessmentsofcaretransitions(eg,informationhandoffs)andcareplanimplementation.
TheotherdomainsofcareintegrationarecriticallyimportantindefiningacomprehensivesetofperformancemetricsthataregearedtowardachievingtheQuadrupleAim.
SLIDE 13 » Measure What Matters
SLIDE 14 » Achieving the Quadruple Aim
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 8
CareintegrationiscorrelatedwithQuadrupleAimoutcomes.
• Improved quality indicators: Care and services are integrated sothatdecisionsaremadecollectivelyandownershipoftasks andresponsibilitiesisdeterminedtogether.Thisclosesgapsinotherwisepotentiallyfragmentedsystems.
• Improved family experience:Familiesfeelmorecohesivewiththeirchildren’scareteams.
• Improved provider experience: Aprovider’sabilitytoprovidecomprehensivecareimproves.
• Reduction of unnecessary costs: The intention is to shift care fromhigh-costutilizationservicestolowercostambulatory,orhome-orcommunity-basedservices.
These are the goals and purposes that care coordination activities canserve.
Share the following evidence for care coordination with the learners usingtheframeworkshownontheslide:
• AccordingtoanAmericanAcademyofPediatrics(AAP)policystatement,theprovisionofcarecoordinationwaspositivelyassociatedwithpatient-andfamily-reported“receiptoffamily-centeredcare,”resultingin“partnershipswithprofessionals,satisfaction with services, ease of getting referrals, lower out ofpocketexpensesandfamilyfinancialburden,fewerhoursperweekspentcoordinatingcare,lessimpactonparentalemployment,andfewerschoolabsencesandEDvisits.”
• AnIllinoisstudyshowedthatchildren,youth,andtheirfamilies hadahigherneedforcarecoordinationwhencommunicationbetweenhealthcareteammemberswasinadequate.
• Carecoordinationwithinprimarycarepediatricpracticesisassociatedwithdecreasedunnecessaryofficeandemergencydepartment(ED)visits,enhancedfamilysatisfaction,andreducedunplannedhospitalizationsandEDvisits.
• Carecoordinationconductedasastandardofpediatricpracticeresultedinincreasedfamilysatisfactionwiththequalityofcare andalsodecreasedbarrierstocare.
(Reference: AAP CC Policy Statement, 2014)
© 2019 Boston Children’s Hospital. All rights reserved.
Contributorstocomplexityincludepsychosocial,socioeconomic,demographic,medical,behavioral,andenvironmentalfactors.Communityleaders,advocates,anddeliverysystemleadersmustconsiderthebroadneedsandassetsofthecommunitywhendefiningcarecoordinationcompetenciesandoutcomes.Understandingthismultifactorialmodelofhealthoutcomesisessentialindesigninginterprofessionalcareteams,withthepatientandfamilyatthecenter.
SLIDE 15 » Matching Services to Complexity
SLIDE 16 » Prevalence of Pediatric Complexity
SLIDE 17 » Evolving the Care Model to Achieve High Value
SLIDE 18 » Impact of Care Fragmentation
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 9
Theprevalenceofcomplexity,chronicconditions,and“typically”functioningchildrenandyouthsuggeststheneedtodefinethecharacteristicsofeachsegmentofthepediatricpopulationwhenone isdevelopingcarecoordinationandcaremanagementcompetencies.
Effectivecarecoordination,especiallyforchildrenandyouthwithspecialhealthcareneeds,requiresaninterprofessionalteam.Thecomplexityofthegivenchild’soryouth’sneedsoftendeterminesthelocusofcarecoordinationandintegration,alongwithhowmultiplestakeholderscollaboratetoachieveoptimaloutcomes.
Familyexperiencewithcoordinatingcarefortheirchildrenandyouthwithbehavioralhealthneedsdemonstratesthatthispopulationisespeciallyvulnerabletocarethatisfragmented,leadingtosignificantstressorsuponfamilies.
© 2019 Boston Children’s Hospital. All rights reserved.
Carecoordinationcanseemlikeagreatconceptbuthardtofigure outhowtooperationalizeandsystematize.
Basedonevidence,theAAPpolicystatementoncarecoordinationincludesrecommendationsforpursuingcarecoordination.
Thisslideincludesexamplesofactionableitemsthatcanhelpachievesomeoftheserecommendations.
SLIDE 19 » AAP Policy Statement
SLIDE 20 » AAP Policy Statement, Select Recommendations
SLIDE 21
SLIDE 22
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 10
TheAAPpolicystatementfacilitatesastructuredapproachtodefiningactivitiesofcarecoordinationandtoaligningkeystakeholdersinimplementationandperformancemeasurements.
FacilitatorsmaywishtohighlightaparticularAAPrecommendationthatispertinenttothelearnersorteam.Usingtheprovidedmodel,suggestactionableitemsforanyrecommendationschosenfordiscussion.
Foreachrecommendationthatisdiscussed,asklearnerstoshareanyactionstheybelievesupportthatrecommendationintheircurrentpractice.Facilitatorscanthenshowsomesuggestedactionsliketheexamplesprovidedinthisslide.
Delineationofrolesandresponsibilitiesincludesthepatientandfamilyaswellasallmembersofthecareteam.Thisprocesspresagesthefunctionalityofthecareplanningtoolknownastheactiongrid,beginningwithslide44inthismodule.
© 2019 Boston Children’s Hospital. All rights reserved.
Identifymembersofachild’scareteam.
Theentireteamisusuallynotlocatedinthesamephysicalspace andisoftengeographicallydispersed.
SLIDE 23
SLIDE 24 » Key Elements of Care Coordination
SLIDE 25 » Objective
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 11
Whatarethingsthatthelearnersdoeverydaythatmightalign withtheserecommendations?Practically,whatdotheymean?
Thisslideincludesaframeworkofwhatcarecoordinationactivitiesmightlooklike.
Askthelearnerstodoapracticeassetsandneedsassessmenttoseewhattheirteamisdoingtosupportcarecoordinationineachofthedomainsincludedintheframeworkandwhichdomainsmayhaveopportunitiesforimprovement.
Facilitatorsshouldsummarizetheobjectiveshere.
© 2019 Boston Children’s Hospital. All rights reserved.
Distributethehandouttoteamsorindividualparticipantsasappropriate.Giveparticipants5minutestocompletetheasset andneedsassessmentasateam(ifapplicable).
Asklearnerstoreflectontheircurrentactivities.
• Whataretheyalreadydoingtoprovidecarecoordination for patients?
• Whatgapsdidtheyidentify?
• Whatareawouldtheyliketoprioritizeasanopportunity forimprovement?
~Encouragethemtoconsiderinstitutionalpriorities,stakeholderinterests,andlocalresources.
Askforsome“headlines”tobesharedinthelargergroup.
SLIDE 26 » Asset and Needs Assessment
SLIDE 27 » Care Coordination Framework
SLIDE 28 » Objective
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 12
Gainingconsensusontheframework,withitsorganizedapproachtodefiningelements,activities,androles,willleadtoarobustapproachtomeasurement.
Facilitatorsshouldsummarizetheobjectivehere.
© 2019 Boston Children’s Hospital. All rights reserved.
Ask learners:
• Doesthiscasestudyresonate?
• Isitrealistic?
• Whatarethegaps??
Informthelearnersthattoday’sdiscussionwilladdresscommon issuesassociatedwithadolescentvisits.
SLIDES 29 & 30 » Case Study: Keystone Pediatrics
SLIDE 31 » Identifying Areas for Improvement
SLIDE 32 » Areas of Improvement
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 13
Askparticipantstoidentifypotentialareasforimprovement. Hereare2opportunitiesthatcanbeexploredfurther:
• Thegapinthestructuredprocessforcompletingwellvisits.
• Thegapinthesystemofreferralsandhandoffsbetweenteammembers.
Thisslideincludescommonissuesassociatedwithfamilywell-visitattendance.
TheAAPpolicystatementoffersseveralexamplesofhowtoimprovetheseissues.
© 2019 Boston Children’s Hospital. All rights reserved.
Thismodulefocuseson2oftheAAPrecommendationsfor carecoordination.Wewilltalkthroughoperationalizingtheserecommendationsandimplementingtoolsandmeasuresto supportthem.
Forexample,howcanmeetingtheneedsofpatientsandfamilies beensured?Thefirststepistounderstandpatientandfamilyexperienceswithhealthcare.
SLIDE 33 » The Focus with Today’s Case
SLIDE 34 » Measuring Patient and Family Experience
SLIDE 35 » Family Experience with Coordination of Care
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 14
Thisslideincludes2toolsthatcanbeusedtomeasurepatientandfamilyexperience.Bothtoolsincludequestionsthatareframedas“inthepast12months.”Versionsofthetoolsareavailablefortransitionsandhandoffs,andbothareavailableinEnglishandSpanish.
• TheFamilyExperienceswithCoordinationofCare(FECC)surveyfocuses on structure and processmeasures,includingtoolsandresourcesthatareavailabletosupportcarecoordination.
• ThePediatricIntegratedCareSurvey(PICS)focusesonoutcome measures,includingfamilyexpectationsofcareintegration.
TheFECCsurveyfacilitatesassessmentof20caregiver-reportedqualitymeasuresforchildrenwithmedicalcomplexity.
© 2019 Boston Children’s Hospital. All rights reserved.
Thisslideincludes1samplequestionfromeachofthe3domainscoveredintheFECCsurvey.
Differentquestionscanbeselectedfromthesurveyandshared withthelearners,dependingontheirinterestsandpriorities.
The full tool is available at: https://www.seattlechildrens.org/research/centers-programs/child-health-behavior-and-development/labs/mangione-smith-lab/measurement-tools/
SLIDE 36 » Family Experiences with Coordination of Care
SLIDE 37 » PICS
SLIDE 38 » PICS
SLIDE 39 » PICS
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 15
PICSisavalidatedoutcomemeasureofpatientandfamilyexperiencewithcareintegration.ThesurveyisalreadybeingimplementedinmultiplesettingsacrosstheU.S.andisbeingconsideredforusebysomestateMedicaidprograms.
PICSassessesparentandcaregiverexperiencewithintegrationacrosstheentirecareteamoraspecificentity(eg,aparticularsubspecialtyclinic).Itassessesparent/family/caregiverexperiencewithmedicalservicedelivery,behavioralhealth,education,andlinkagetocommunityorganizations.
PICScontains19experience-relatedquestionsin5domains:access,communication,familyimpact,caregoalcreation,andteamfunctioning.
ThisslidecontainssomeexamplesfromPICS.
Differentquestionscanbeselectedfromthesurveyandshared withlearners,dependingontheirinterestsandpriorities.
The full tool is available at: http://www.childrenshospital.org/integrated-care-program/patient-and-family-experience-outcome
© 2019 Boston Children’s Hospital. All rights reserved.
Inadditiontothetoolsformeasuringpatientandfamilyexperience that have been shared during the session, patient experiencetoolsarealsoavailablefromPressGaneyandNRCHealth.
However,thisnextportionofthemodulewilllookattoolsthat canbeusedtosupporthigh-qualityhandoffsbeforeandafteraclinicalencounter.
SLIDE 40 » Tools to Support High-Quality Handoffs
SLIDE 41 » High-Quality Handoffs
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 16
What is a handoff? Itisthetransferofpertinentknowledgebetweenmembersofapatient’scareteam,enablingacareteammembertosafelyassumeresponsibilityforsomeaspectofcare.
Handoffsoccurinnumerouscontexts:
• Toandfrompediatriciansandotherphysicianstopediatricsubspecialists,pediatricsurgicalspecialists,ornonphysicianclinicians
• Toandfromcommunitiesandhospitals
• Toandfromanon-callphysiciansandnonphysicianclinicians
• Toandfrompediatricmedicalsubspecialistsorpediatricsurgicalspecialists on other services
Thegoalofahandoffistoenablethecareteamtomaximizethe utilityofeverypatientinteractionbyensuringknowledgelearned byonepartofapatient’scareteamiscommunicatedtoother membersattherighttimeandplace.
Structuredhandoffcommunicationusingastandardizedtemplate inconcertwithteamtraininghasbeenassociatedwithreducedmedicalerrors(Starmeretal.2014).
© 2019 Boston Children’s Hospital. All rights reserved.
Asklearnerswhatsomeofthekeypiecesofinformationarenecessarytooptimizingclinicalencounterswithpatientsandfamilies.
InformthemthatauditsacrosstheUnitedStatesdemonstratethatonly5%to20%ofreferralstopediatricmedicalsubspecialistsandpediatricsurgicalspecialists(?)includepediatricians’orotherphysicians’reasonsforrequestingconsultations,andinformationaboutevaluationsconductedtodate,andexpectationsofconsultations.
Itmaybehelpfultoclarifyherethedistinctionbetweenareferralrequesttoapayertoobtainapprovalandaphysician-informedornonphysicianclinician-informed reason for subspecialty consultation.Thiscurriculumfocusesonthelatter.
SLIDE 42 » Collaborative Consults
SLIDE 43 » High-Quality Handoffs: Collaborative Consults
SLIDE 44 » High-Quality Handoffs: Closing the Loop
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 17
Thisslidefeaturesamodeltemplatethatcanbeusedtoensurethattheelementsincludedinthetemplateareavailablepriortoeveryencounter.
This template is available to learners at: http://www.childrenshospital.org/integrated-care-program/high-quality-handoffs.
TheHigh-QualityHandoffstoolcanbeusedtostructureessentialinformationforeachmemberofthecareteam.Thiswouldinclude caretransitionsfromprimarycaretosubspecialist,subspecialisttoothersubspecialist,orprimarycaretoothermembersofthecare team,suchasnursing,socialwork,andcommunity-basedproviders.
Askthelearnerswhatsomeofthekeypiecesofinformationarethatneedtobediscussedwiththepatientandfamilyand/orothermembersofthecareteamfollowingaclinicalencounter.Also,whatneedstobedonetoensureclearcommunicationofpatientandfamilygoalsandtheplanofcarewithatimelineandresponsibilityforimportanttasks?Whatpracticessupportreliableinformationsharingamongmembersofthehealthcareteamsothatnothingfallsthroughthecracks?
Thesearecommonchallenges,particularlyacrosstransitionsincareandwhenteammembersaredispersedacrossmultiplesites.
Informthelearnersthatthenextpartofthesessionwilldescribeatoolthatsupportsasharedmentalmodelandclosed-loopcommunicationacrossthecareteam.
© 2019 Boston Children’s Hospital. All rights reserved.
Anactionitemgridisdevelopedwiththepatientandfamily.Itoutlinesanoverallcaregoal,tasktobecompleted,whoisresponsible,timelineforcompletion,andacontingencyplan.Thehigh-qualityhandoffisacriticalfirststeptoinformthepatientencounter,and theactiongridhelpsensureclosed-loopcommunicationbacktothereferringcareteam.
This template is available to learners at: http://www.childrenshospital.org/integrated-care-program/multidisciplinary-care-planning
SLIDE 45 » Closed-Loop Communications: Action Grid
SLIDE 46 » Principles of the Action Grid
SLIDE 47 » Pause for Reflection
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 18
Sharethekeyprinciplesoftheactiongridfromthisslidewiththelearners.
Ofnote,finalizingtheactiongridmaytakemoretimethanwhat isavailableduringasingleappointment.Theactiongridshouldbeaccessibleandsharedacrossthewholecareteam,asdefinedby familypreferences.
Ifitsupportsthelearners’goalsandtimepermits,usetheactivity fromcasestudy#1toguidelearnersthroughaclinicalscenario usingtheactiongrid.
Allowlearnerstodiscussinsmallgroupspriortosharingafewexampleswiththelargergroup.
© 2019 Boston Children’s Hospital. All rights reserved.
Returningtothecasestudyexample,askthelearnerstothinkabouthowthesetoolscanbeusedtomeasureandaddressthegapsincarethatwereidentified.
SLIDE 48 » Intervention
SLIDE 49 » Collaborative Consults
SLIDE 50 » Action Grid
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 19
Astructuredapproachtodefiningrolesandresponsibilitiesisessential,whetheritisforpatientswithchronicandcomplexneeds orthosewithstraightforwardandnoncomplexneeds.Thetoolfeaturedonthisslidecanbeadaptedfornonmedicalinteractions aswell(eg,behavioralhealthorsocialservice).
Theactiongridiscocreatedwiththepatientandthefamilyor caregiver.Itassuresclarityandtransparencyacrossallmembers ofthecareteam.Italsospecifiesadesiredgoal,necessaryactivities, atimeline,andtheaccountableentity.Theactiongridtemplatewascreatedasaresultoffamilyreportsabouthowtoreducefragmenta-tionofcareaspartoftheprojectthatcreatedthePICSinstrument.Experiencehassincerevealedthathealthcareteammembersalso findthistoolusefulforessentiallythesamereasonsasfamilies.
© 2019 Boston Children’s Hospital. All rights reserved.
Asklearnerstoreflectontheirexperiencesasacareteammemberand/orfamilymember.
ThesequestionsarefromthePediatricIntegratedCareSurvey(PICS).FeelfreetouseothermeasuresfromthePICSiftheyaremorerelevanttoacasestudythathasbeenadapted.
SLIDES 51 & 52 » Implementing a Shared Plan of Care
SLIDE 53
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 20
Askthelearnerstoconsiderhowtheywouldoperationalize the following phases for this particular case:
• Phase 1: Family outreach/engagement Thefamilywasinvitedandprovidedwithathoroughdescription
ofwhatacarecoordinationinterventioncoulddotohelpthem, andtheyagreedtoparticipate.
• Phase 2: Family and team pre-visit work An assigned care coordinator reached out and learned that the
familyhadnomeansoftransportation,thefatherhadnowork leavetime,andtheirEnglishwasverylimited.Theywouldrequirethe following supports to ensure a successful period of care coordination:aMedicaidcab,acarseat,aspecificdialecttranslator,andavisittimedtothefather’sschedulebecause hedoesthecommunicationforthefamily.
• Phase 3: Population-based teamwork TheteammemberssharedinsightsintoBurmesecultureand
addressedtheinterventionsneededtohelpthefamilyattendaplannedcarevisit(transportation,interpretation,safety,etc.). Theteammembersreviewedthemedicalrecordandotherdocumentsandbegantopopulatethemedicalsummary.
© 2019 Boston Children’s Hospital. All rights reserved.
The 10 steps found on this slide are foundational for ensuring a broad, strategicapproachtoimplementingasharedplanofcare.
SLIDE 54 » Ten Steps to Achieving a Shared Plan of Care
SLIDE 55 » Objective
SLIDE 56 » SMART Goals
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 21
Thistrainingsessionhasaddressedidealelementsofcarecoordinationinhigh-functioningclinicalteams,potentialgapsinclinicalpractices,andpracticalstrategiesandtoolsforachievingAAPrecommendationsforcarecoordination.
Thecontentcoveredthusfarwasintendedtoequipthelearnerswithconcreteideasforimplementingneededcarecoordinationactivities…tomorrow!
Now,itistimeworkondevelopinganactionplan. [hand out action plan worksheet]
Askthelearnerstoreflectasateam(orindividually)ontheirneedsassessmentfromthebeginningofthetrainingandsomeofthestrategiesandtoolsthathavebeendiscussed.
Asklearnerstoidentify1short-termgoal(within7days)and1long-termgoal(within90days)theyhavetoimprovecarecoordinationintheirpractices.
SharethefollowingmnemonicforSMARTgoalsetting:goalsshouldbeSpecific,Measurable, Achievable, Relevant, and Time-bound.
© 2019 Boston Children’s Hospital. All rights reserved.
Now,asklearnerstoconsiderthefollowingquestionsforeachgoal:
• Whatbarriersdoyouanticipate?
• Whatisyourspecificplantoachievethisgoal?
Consideringthesetypesofquestionshavebeenshowntoimprovetransfer of training to the work setting and to increase likelihood of follow-throughongoals.
Invite 3 to 4 participants to share their goals and action plans with the largegroupandtoobtainfeedback.
Then,discussfollow-up.
Consider:
• Havingteamsmailaletterwithinadefinedtimeframe tothemselveswithacopyofthisworksheet.
• Havingteamsemailasupervisor,director,orotheridentifiedleadertoensureaccountabilityandtoarrangeacheck-in.
• Arrangingafollow-upphonecallwiththemodulefacilitator.
SLIDE 57 » Your Action Plan
SLIDE 58 » Take-Home Points
SLIDE 59 » Take-Home Points
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 22
The facilitator should get a sense of how the diverse group of learnershasreactedtothedynamicofthesession,aswellaswhetherthe participants have been able to integrate the content into their cognitiveframing.
Encourage the group to reflect on the following:
• Howcanyoubegintoimplementcarecoordinationinyour workinthenextfewdays?
• Whataresomedriversthatwillencouragebroadadoption?
• Howcanoutcomemeasurementbeimplementedtoassuresustainability?
© 2019 Boston Children’s Hospital. All rights reserved.
SLIDE 60 & 61 » Resources
Facilitator Guide–Slide Deckcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 23© 2019 Boston Children’s Hospital.
All rights reserved.
Module 1Pediatric Care Coordination Curriculum 2nd Edition 24
Whatcanbedonetoensureclearcommunicationofthepatient’sandfamily’sneeds andplannedcarewithacleartimelineandresponsibilityforimportanttasks?
Whatpracticessupportreliableandbidirectionalinformationsharingamong membersofthehealthcareteamsothatnothingfallsthroughthecracksacrosstransitions in care?
Note to the facilitator: Thismoduleincludesaclinicalscenariothatcanbeusedtoillustratepracticalwaystooperationalizetheaboverecommendations.Thisscenariocanbeadaptedoranewscenariocanbedevelopedthatresonateswiththeparticipants.Forexample,insteadofhavingparticipantsplacethemselvesintheshoesofapediatricianorotherphysician,theycoulddiscussthecaseofasubspecialistoralliedhealthproviderwhoisseekingtodeveloprecommendationsandcommunicatethemtoprimarycare,communityagencies,orschool.Ensurethecasehasthefollowingelements: • Patientcharacteristics(Whattypesofpatientsdotheparticipantssee?Istherea
particulardiseaseprocessorfunctionalchallengecommonlyfacedamongtheparticipants?)
• Clinicalsetting(Inwhatsettingarepatientstypicallyseen?Isitaninterprofessionalclinic,privatepractice,specialtyconsultantservice,orcommunityagency?)
• Need(s)tobeaddressedoutsideoftheclinicalsetting(Thismayincludeasubspecialtyreferralthatisbeingplacedforaclinicalquestion,afollow-uprequiredwithapediatricianorotherphysician,oraconcernraisedinaschoolorcommunity settingorbyabehavioralhealthclinician.)
Independentlyreadandreflectonthefollowingcasethendiscussitinyoursmallgroup.After5minutes,wewilldebriefasalargergroup.
Case-Based Learning
AAP policy statement recommendation #3: Continuallyinvolveandengagethepatient/family(eg,familiesaspartners/advisors),buildonthestrengthsofthepatient/family,clearlydelineateresponsibilitiesofteammembers,andcreatecarefulhandoffswhentransitioningacrosssettings(eg,betweeninpatient and outpatient settings and between pediatric and adult care providers, systemsand/orsettings).
AAP policy statement Recommendation #5: Usecarecoordinationacrosstransitionsbetweenentitiesofthehealthcaresystem(eg,betweenandamongpatientcareteams,acrosssettings,betweencaregivers,andbetweenhealthcareorganizations)andwithtransitionsovertime(eg,acrossthelifespan,betweenepisodesofcare,andacrosstrajectoryofillnesses).
AAP policy statement recommendation #6: Ensurethatco-managementandcommunicationoccuramongspecialistsandprimarycareproviders.Thiscaremodelrequiresreciprocalandbidirectionalcommunication(eg,securee-mails,phonecalls,notes,andfaxes),whichcanbeaugmented,butnotreplaced,withhealthinformationtechnology.
CASE STUDY #1
Sharing Information and Coordinating Care Across Transitions
© 2019 Boston Children’s Hospital. All rights reserved.
Module 1Pediatric Care Coordination Curriculum 2nd Edition 25
EricEricisa12-year-oldboywithsicklecelldiseasewhohadarecentischemicstroke,whichhasledtothedevelopmentofaseizuredisorder.YoucoordinateEric’scare intheprimarycareclinicandarereviewinghiscasebetweenvisits.Heisalreadyfollowedinthegeneralneurologyandsicklecellhematologyclinics.Athislastneurologyappointment,transferringrecommendationwasmadetotransferEric’s caretoapediatricstroketeamatthelocaltertiarycarecenter.YoualsoseethatEric’smothercalledthecliniclastweek,expressingconcernthatEric’slearningdifficultieshaveworsenedatschool,andyourecognizethathisindividualizededucationplan fromschoolneedstobeupdated.
• Whoaretheteammembersthatneedtocometogethertobest coordinateEric’scare?
• Whattransitionisoccurring?
• Whatneedsandcaregoalscanyouidentify?
• WhatactionswillyoutaketocoordinateEric’scaretoensureasmooth transitionforEricandhisfamilyacrossmultiplesettings?
• Whatchallengesmightyoufaceinthisprocess?
Probe:WhoarethenewmembersonEric’steam? Howwillyoucommunicatetheserolestothefamily?
Note to the facilitator: Assmallgroupsdiscusstheirresponses,consideroffering thefollowingprobingquestionstostimulatediscussion:
• HowwillyoucommunicatewithEric’sfamilyregardingthenewmembership androlesinhishealthcareteam?
• Howwillyoushareinformationbetweenmembersofthehealthcareteam?
• WhattoolsorresourcesmightyouneedtobestassistEricandhisfamily?
After5-10minutes,debriefinalargergroup.Write2headingsontheboard:“Challenges”and“Actions.”Askeachsmallgrouptosharetheir“headlines”— 1or2keypointsthattheydiscussedorkeyquestionsthattheyhad.
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 26
Actions may include:
• NotifyEric’sfamilyoftherecommendationtoreferhimtoastrokeclinic.
• Sendthereferraltothestrokeclinicadministrationwitharecommendedtimeframe.
• ContactthefamilytoensuretheschoolisawareofEric’smedicalconditionand risks,andcommunicatewiththeclinicnursetoensurethatanymedicationsneededatschoolhaveanupdatedmedicationorder.
• ReconveneameetingwithEric’sschoolteamandadvocateforareevaluation tobecompletedorfinanciallysupportedthroughtheschool.Considerexploringwhetherhavingtheassessmentcoveredbymedicalinsuranceisafeasibleand/orfasteroption.
• ExplaintoEric’sfamilyexactlywhotheirnewhealthcareteamis(pediatrician,neuropsychologist,administrativeassistant,nurse,etc.)andwhotocontactforpotentialissues(i.e.,Whowillmanagefeversorurgentcareneeds?Whowillprescribeandmonitoreachmedication?Identifytheneedforafeveractionplan in the care plan, outlining steps to initiate, who to call, and when to take Eric to theemergencydepartmentforafeverorpaincrisis.)
• DevelopandupdateacareplanforEric.Includethenames,roles,andcontactinformationforeachcareteammember.(Decidewhoisresponsibleforupdating andmanagingthecareplanamongthemultiplepartnersinvolvedinEric’scare.)
• Ensurethecareplanisaccessibletoallmembersofthehealthcareteam(i.e.,in theelectronichealthrecordandpatientorfamilyportalandgiveahardcopyto thefamily).
• Advisethefamilythatiftheyhavenotheardfromthestrokeprogramadministrationin2weeks,forexample,theyshouldcontacttheclinicdirectly.
~Tellthefamilythatthistypeofactionisanexampleofcontingencyplanning—outliningstepstobetakenifexpectedresultsdonotoccurandpreparingforalternativeoutcomestoensureimmediateandappropriatefollowupofpotentialissues.
~Also,highlighttheimportanceofclosingthelooponthisreferral—makeaplantoreconnectwiththefamilyorclinictoensuretheappointmentwasmadeandattended.
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 27
Challenges may include:
• EnsuringEricisseenbythestroketeaminatimelyfashionandestablishing amechanismtofollowuponthis
• MaintainingcommunicationwithEricandhisfamilysotheyareawareofthetransitiontothestrokeclinic,understandtherolesofthenewcareteammembers,andunderstandwhoisresponsibleformanagingeachpotentialhealthissue
• Developingacomprehensivecareplanandcomanagingwithcareteammembersindifferenthealthcaresettings
• Identifyingapointpersontocoordinatecareteammemberrolesandfollowup onactionitems
• Ensuringaccessibilityofthecareplan—formsofcommunicationthatarereliableand secure
• CommunicatingwithEric’sschoolandarrangingforaneuropsychologistevaluationtoinformanewindividualizededucationplan
• Ensuringthecareplanisupdatedconsistentlyandaccurately,reflectingall ofthecarebyEric’scareteam
Didactic
Slide: Coordinating Care Across Transitions
Transitionsincarearefrequent!Eachtransitionshouldbeaccompaniedbyathoughtfulhandofftoensureimportantinformationisn’tlostorforgotten.
• Handoff:Thetransferofpertinentinformationbetweenmembersofapatient’scareteam,enablingthepersontosafelyassumeresponsibilityforsomeaspectofcare.
• Handoffsoccurinmultiplecontexts: ~Toandfromthecommunityandhospital ~Toandfromanon-callphysicianornonphysicianclinician ~Toandfromaconsultant ~Toandfromamedicalsubspecialistorsurgicalspecialistonanotherservice ~Toandfromhomecareservices ~Frompediatrictoadultcareteammembersorsettings
Facilitator notes: This training session has addressed suggested actions that thelearnerscantaketotheirpracticetofacilitatesmoothtransitionsincareforpatientslikeEric.Herearesometoolsthatcanhelpthelearnersimplementtheseactions…tomorrow!
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 28
Slide: Tools for Ensuring Smooth Transitions in Care
• Collaborative consults: outlining the purpose of a visit, relevant clinical information, requested referral relationship, and timeline
• Caremapping:creatingavisualrepresentationofapatient’scareteammembersincollaborationwiththefamily,discussingrolesandwho-tolinesofcommunication
• Action grid: development of an action item grid with the family outlining the overall care goal, task to be completed and person responsible for completing the task, timeline for completion, and contingency plan
• Careplan:acomprehensive,integrated,shared,anddynamicdocumentthatincorporatesasummaryofmedicalissues,careteammembership,prioritized goalsofcare,andnecessaryactionstoachievethegoals
Facilitator notes:Demonstratehow2ofthesetoolscouldbeusedinEric’scase.
Slide: Collaborative Consults
Reason for Visit
First-timeevaluationformultidisciplinarycarefollowingischemicstrokeinachildwithsicklecelldisease.
Requested Referral Relationship
4 One-timeconsultation
4 Comanagement/sharedcare
4 Subspecialty-basedmanagement
p Tobedetermined
Relevant Clinical/Psychosocial Information
12-year-oldboywithhistoryofsicklecelldisease.Developedaseizuredisorderfollowingischemicstroke, hasbeenfollowedingeneralneurologyprogramuptothispoint.Learningdifficultiesnotedatschool.
Question to Be Answered
WhatsurveillanceisrequiredgivenEric’shistoryofischemicstroke?
Pediatric Stroke Program Referral
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 29© 2019 Boston Children’s Hospital.
All rights reserved.
Case-Based Learningcontinued
Slide: Action Grid
Transfer of care to the pediatric stroke program
Neuropsychologicalevaluationtoinform anewIEP
Ensure school has updatedmedicalinformation
Incorporateplans/recommendationsfromallspecialistsandPCPs,IEPcompo-nents, specialists into care plan
Engage patient and familytoobtaininputandidentifyneedsandtheir goals
Distribute care plan to membersofthehealthcareteam.
Referral sent on Jan 2ndrequestinganappointmentwithin 4weeks.
WillestablishschoolcontactJan9thandconveneschoolteammeetingtoplanreevaluation.
WillcallschooltheweekofJan9th.
Willcollectthisinputpriortoappointmentbelow.
Appointmentarrangedfor week of Jan 16th to discusscareplan.
NurseandPCPwillsend care plan to the patient portal and email/mailacopytoparents, school, specialists for review andtocommunityrecreation center after aboveappointment.
Iffamilyhasnotreceivedacallfromthestroke clinic in 2 weeks, theyshouldcalltheclinicdirectlyat (111)111-1111.
Clinicadministrativeassistant will contact familyin2weekstofollowuponreferral.
Social worker will contactfamilytheweekof Jan 16th to coordi-natemeetingandsharecareplanwithschool.
Nursewillcallfamilytoconfirmwhencontacthasbeenmade.
Ensure appointment management and preventative care for stroke and its sequelae
Support Eric’s learning at school
Update/maintain care plan for Eric with input from all team members and family
ActionGoalWho is responsible Timeline Contingency
WhatpracticeswillYOURTEAMusetoshareinformationandcoordinatepatientcareacross transitions?
Wehavediscussed2toolsthatyoucanusestarting tomorrow: • Thecollaborativeconsult • Theactionitemgrid
PCP
Social worker
Clinic nurse
Clinic nurse/PCP
Clinic nurse/PCP
Clinic nurse/PCP
Module 1Pediatric Care Coordination Curriculum 2nd Edition 30© 2019 Boston Children’s Hospital.
All rights reserved.
Case-Based Learningcontinued
AAP policy statement recommendation #1: Useandcreatemechanismsforpatients/familiestolearntheskillstheymayneedto be partners in their own care andindecision-makingforoptimalcarecoordination.
AAP policy statement Recommendation #2: Ensurethatthepatient’sandfamily’sneedsforservicesandinformationsharing (eg,careplanning)acrosspeople,systems,andfunctionsaremetvia(a)formalassessments,(b)infrastructure(eg,teams),and(c)tracking(eg,registries); thisiscrucialinoperationalizingcarecoordination.
AAP policy statement recommendation #4: Useanddevelopefficientandaccreditedhealthinformationsystemsandinformationtechnologyadvancestofostersuccessfultransferofinformation;tosupportcollaborativecommunicationsbetweenpatients,families,andthecareteam; andtofacilitateshareddecision-making(eg,developingandusingcareplans).
AAP policy statement recommendation #5: Usecarecoordinationacrosstransitionsbetweenentitiesofthehealthcaresystem (eg,betweenandamongpatientcareteams,acrosssettings, between caregivers, and betweenhealthcareorganizations)andwithtransitionsovertime(eg,acrossthelifespan,betweenepisodesofcare,acrosstrajectoryofillnesses).
AAP policy statement recommendation #6: Ensure that comanagementandcommunicationoccuramongspecialistsandprimarycareproviders.Thiscaremodelrequiresreciprocalandbidirectionalcommunication (eg,securee-mail,phonecall,note,fax),whichcanbeaugmented,butnotreplaced,withhealthinformationtechnology.
AAP policy statement recommendation #7: Ensure ongoing educationofelementsofcarecoordinationandthemedicalhome forpracticingphysicians,nursepractitioners,physicianassistants,nurses,medicalstudents,residenttrainees(acrossdisciplines),mental/behavioralhealthcarepractitioners,socialworkers,andotherhealthcareprofessionalsviaspecific training/curricula,continuingmedicaleducationprograms,andpublications.
AAP policy statement recommendation #10: Understandandusenewcarecoordinationcodes(99487–99489;99495-99496) and advocateforpaymentofthesecarecoordinationservicesbypayers.
CASE STUDY #2
Care Planning and Coordinating Care Across Transitions
• Whatcanbedonetofacilitateshareddecision-makingforfamiliesandfostercare integration?
• Howshouldcareteammembersengagepatientsandfamiliesincareplanningandshareddecision-making?
• Whatstrategiesandtools(eg,healthinformationtechnology)cancareteammembersuseincomanagementandtoensureaneffectivetransitionofcare?
• Whatbillingcodescanbeusedtohelpsupportthetimespentincoordinatingcare in practice?
Independentlyreadandreflectonthefollowingcasethendiscussthecase inyoursmallgroup.After5minutes,wewilldebriefasalargergroup.
Module 1Pediatric Care Coordination Curriculum 2nd Edition 31
LuciaLuciaisa14-year-oldfemalewithspinabifida,whoyouhavecaredforsincebirth.Youandyourteamaretheprimarycarecliniciansandworkcloselywithherspecialtyteam,includingorthopedics,urology,neurology,andphysicalmedicineandrehabilitation. Hermother,asinglecaregiver,hasbeenforcedtomoveseveraltimesduetohousinginstabilityandfinancialchallenges.YouhavestartedtoaddressLucia’sadolescence,including learning self-care, in recent visits to allow her independence at school and in thecommunity.Yesterday,hermotherleftamessageforyouindicatingconcernabout arecenthospitalizationandnewurologyteam.ShestatedLuciawasrecentlyadmittedandtherewere“changesbeingmade.”Uncertainofthenewplanandnewmedications,shealsostatedtheyhadnotreceivedthenewcathetersfromthemedicalequipmentcompanythatwereorderedatthelasturologyvisit.
• DiscusstheteammemberswhoareneededtobestcoordinatecareforLucia.
• IdentifysomeofthepsychosocialissuesthatneedtobeaddressedwithLucia’smotherasoneofthecareteammembers.
Probe:Thinkaboutfamily-centeredcareandbuildingtrust.
• WhataspectsofcaretransitionneedtobeaddressedforLucia? ~Transitiontoadult-orientedsystems(self-care) ~Transitionofcareacrosssettings,fromhospitaltohome
• Whatisthebiggestchallengeincoordinatinghercare?
Facilitator notes:Assmallgroupsdiscusstheirresponses,considerofferingthefollowingprobingquestionstostimulatediscussion:
• Socialdeterminantsofhealthhaveaprofoundimpactonhealthoutcomes.Somesocialdeterminantsofhealthincludepoverty,literacy,foodandhousingsecurity,environmentalrisks,healthinsurancestatus,immigrationstatus,interpersonalandneighborhoodsafety,energysecurity,andtransportationneeds.
• WhatrolearethesocialdeterminantsofhealthplayingincaringforLuciaand herfamily?
• Howcanyouensuremedicalneeds,communitypartners,andidentifiedresourcesarepartofthecareteamandcareplanning?Thinkabouttherolesofthehospitalistteam,dischargeplanningteam,andmedicalequipmentproviders.
• Whattoolscanfostercomanagementandensurecommunicationacrosssettings?Thinkaboutcareplanning,patientportals,shareddecision-making,andtransitionofcareplanning.
After5-10minutes,debriefinalargergroup.Write2headingsontheboard:“Challenges”and“Actions.”Askeachsmallgrouptosharetheir“headlines”—1to2keypointstheydiscussedorkeyquestionstheyhad.
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 32
Actions may include:
• MeetwithLucia’smothertobetterunderstandherhousingandfinancialchallengesandidentifyresourcesthatmayhelpher.
~Connecthertocommunitypartner(s)andresourcesthatcanassistheror asocialworkerwhocandiscusspotentialoptionswithher.Besuretofollow uptoconfirmthatthisconnectionoccurredtoclosetheloop.
~Consideremployingascreeningtoolforsocialdeterminantsofhealthtofacilitateaproactiveapproachwithpatientsandfamilies.Recognizethatfamiliesmaybemorelikelytodisclosefinancialstrugglesandchallengesrelatedtosocialdeterminantsofhealthonpaperversusface-to-facescreening.
• Contacttheurologygrouptobetterunderstandanychangesmadeandplansforfollow-up,necessaryequipment,andmedicationchanges.BesuretocheckthatLucia’smotherisawareoftheseplansanddemonstratesanunderstandingof therecommendations.
• WorkwithLucia’smothertosetgoalsforLucia’scareandensureherunderstandingofLucia’smedications,care,andequipmentandencourageherunderstandingofshareddecision-making,bothinyourofficeandwithothercareteammembers.
• DevelopandmaintainacareplanforLuciathatincludesallofherspecialistinformation,medicalequipmentproviders,therapists,IEPinformation,communitynursingservices,medications,communityproviders,school/educationalinformation,names,phonenumbers,homenursinginformation,insurance, andsupplies(eg,size,amount,andtypeofformula).
~BesurethatLuciaandhermotherreviewandinformthecontentofthe careplanpriortofinalizingthecontent.
~Ensurethattheroleofeachcareteammemberisoutlinedinthecareplan soLuciaandhermotherknowwhotocontactforissuesastheyarise.
~WorkonreconcilingthehomenursingordersforLuciawithyourcare plan,ensuringaccuracy,parentgoalsbeingmet,andsmoothcommunicationaboutLucia’sneeds.
~Trackyourtimecoordinatingcare,andbillcarecoordinationcodes (99487–99489)asoutlinedinthecontractswithLucia’sinsurancecarrier.
• ProvideLuciaandhermotherwithseveralhardcopiesofLucia’scareplan.Fax oremailLucia’scareplantothespecialistsinvolvedinhercare,theappropriatecontactsatherschool,hertherapists,andhermedicalequipmentproviders.
• AddLucia’scareplantoherpatientportaltomakeiteasilyaccessibleforhermother.
~EnsurethatLucia’smotherunderstandshowtologintothepatientportalandaccessitviahersmartphone,andwhenLuciaishospitalized,howtoaccessthepatientportalincommunitysettingsandcommunicatethecareplanacrosssettings.
• WorkwithLuciaandhermotherontransitioncareplanningforadult-orientedcare.Considerusingaself-managementtooltobegintoteachLuciaaboutself-careandspinabifidaandtoassessherreadinesstotakeamoreactivepartinherhealthcare.
• ContactthehospitalistteammanagingLuciaduringahospitaladmission,and haveyourcarecoordinatorconnectwiththedischargeplanningteamtobetterunderstandtheeventsthatoccurredduringheradmission,recommendations, andherdischargeplan.
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 33© 2019 Boston Children’s Hospital.
All rights reserved.
Case-Based Learningcontinued
• Talkwiththehospitalteamtodeterminetheoptimalprocessforachievingbidirectionalcommunication(includingphonecallsandsharingofinformation)whenyourpatientsareadmittedtothehospital.
~Discussroles,teammembers,andinformationsharing,includingcare plansandreasonsforadmissions).
~Considerimplementingpost-dischargefollow-upcallsforallofyourpatientsfollowinghospitalizationstoassessfamilies’understandingofdischargeinstructions,necessarymedications,priorauthorizations,andneedforfollow-upvisits.
~Establishastandardofcareforschedulingpatientsforpost-hospitalizationswithin7to14days.
~Familiarizeyourselfwiththerequiredcommunication,documentation,timingofpost-dischargevisits,andbillingcodesforpost-hospitaldischargevisits(99495and99496).
• ExplaintoLuciaandhermotherwhothemembersofLucia’shealthcareteam are(physicians,nonphysicianclinicians,mentalhealthpractitioners,communitypartners)andwhotocontactforpotentialissues(ie,Whowillmanagefeversorurgentcareneeds?Whowillprescribeandmonitoreachmedication?Whowillorderandmanageequipment?).BesurethisisclearonLucia’scareplan.
• Setupameetingwiththetop3insurancecarrierstodiscusspaymentforcodesassociatedwithcarecoordinationandhospitalfollow-up.Ifthesecodesare notincludedinyourcurrentcontract,explaintheamountofcommunication thatisrequiredbyyouandyourteamforcarecoordinationandhospitalfollow-up.Discusspossiblebenefitsforpatients,yourpractice,andthepayer,andpaymentstructures.
~Transitionofcarecodes(99495and99496) ~Carecoordinationcodes(99487–99489)
• Workonregulareducationsessionsand,possibly,astaffretreatonpatient-andfamily-centeredcare,teambuilding,huddles,transitionofcareplanningandcaretoadult-orientedsystems,andtheroleofcarecoordination.Besuretoincludephysicians,nursepractitioners,physicianassistants,nurses,medicalstudents,residenttrainees(acrossdisciplines),mental/behavioralhealthcarepractitioners,socialworkers,communityhealthworkers,parentpartners,andcommunitypartners.
• Engageparentpartnersinyourpracticetogivefeedbackandparticipateincarecoordinationeducationforyourstaffsupportingthecriticalroleoffamily-centeredcare.
• AdviseLucia’smotherthatifshehasnotreceivedhernewcatheterswithin 24hoursorhasanyquestionsaboutmedicationadministration,sheshould contacttheclinicdirectly.
~Highlightthistypeofactionasanexampleofcontingencyplanning—outlining steps to be taken if expected results do not occur and preparing foralternativeoutcomestoensureimmediateandappropriatefollow-up ofpotentialissues.
~InstructLucia’smothertomakeafollowupappointmentwiththeurologyofficeandtocontactyourofficewithanyissues.Ensuresomeonefrom yourofficeisfollowingupwithher.
Module 1Pediatric Care Coordination Curriculum 2nd Edition 34
Challenges may include:
• ThesocialdeterminantsofhealthchallengesfacingLucia’smother,includinghousingandfinancialinstabilitywiththelackofhandicappedaccessiblehousing,andlackofresources,time,andsocialworkersinpractice.
• Understandingandlaunchingthetransitiontoadult-orientedsystemswith Luciaandhermother,andaddressingself-care.
• Gettingteambuy-inacrossthepracticeforcarecoordinationtrainingandunderstandingrolesanddefinitions.
• Workingwithinsurancecompaniesoncodingandpaymentforcarecoordinationandtransitionofcare.
• EnsuringadequatecommunicationwiththehospitalistteamandthespecialistscaringforLucia.
• EnsuringthatLucia’smotherunderstandsshareddecision-makingand canadvocateforherself.
• Developingacomprehensivecareplanandcomanagingwithcareteam membersindifferenthealthcaresettings.
• RemindingLucia’smomabouttheavailabilityofthecareplaninthe electronicpatientportal.
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 35
Didactic
Slide: Social Determinants of Health
• Conditionsintheplaceswherepeoplelive,learn,work,andplaythatcan informtheirhealthrisksandoutcomes
• Theroleofpatient-andfamily-centeredcareandtrust
• Examples: ~Housing ~ Access to food ~ Transportation ~Exposuretocrime,violence,domesticviolence,interpersonalviolence ~ Social support ~Accesstoeducational,economic,andjobopportunities
• Identifyandworkwithcommunitypartners. ~WIC,housingresources,HUD
• Usetoolsdesignedforsocialdeterminantsofhealth ~Foodinsecurity ~Adversechildhoodevents(urban)
Slide: Care Coordination Tools
• Careplanninglistofcomponentsforacareplan • Instructionsforpatientaccesstothepatientportal • Patienthuddles • Shareddecision-makingforfamilies
Slide: Transition to Adult-Oriented Systems Tools
• Sixcoreelementsoftransition ~Transitionpolicy(Facilitator note: Have teams work through
what their ideal transition policy might include) ~ Transition index for practices
• Self-managementtools/transitionreadinessassessmenttools ~OnTraq ~Assesscaregiversandyouthwhenappropriate ~Addressguardianshipandpowerofattorneywhenindicated
• Gottransition.org
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 36
Slide: Billing for Care Coordination Services and Transition of Care
CARE COORDINATION 99487–99490Chronic care management services,atleast20minutesofclinicalstafftimedirected byaphysicianorotherqualifiedhealthcareprofessional,percalendarmonth, withthefollowingrequiredelements:
• Multiple(2ormore)chronicconditionsexpectedtolastatleast12months, or until the death of the patient
• Chronicconditionsplacethepatientatsignificantriskofdeath, acuteexacerbation/decompensation,orfunctionaldecline
• Comprehensivecareplanestablished,implemented,revised,ormonitored
99487: Usedifanonphysicianstaffmemberspendsmorethan 1hourovera30-dayperiodoncarecoordination
99488: Includes1hourofcarecoordinationwithanonphysician and a face-to-face visit
99489: Usedfor30-minuteincrementsovertheinitialhour ofcarecoordination.
TRANSITION BETWEEN CLINICAL SETTINGS 99495 Transitionalcaremanagementserviceswiththefollowingrequiredelements:
• Communication(directtelephonecontact,telephone,electronic)withthe patientand/orcaregiverwithin2businessdaysofdischarge
• Medicaldecision-makingofatleastmoderatecomplexityduringtheserviceperiod
• Face-to-facevisitwithin14calendardaysofdischarge
99496 Transitionalcaremanagementserviceswiththefollowingrequiredelements:
• Communication(directcontact,telephone,electronic)withthepatientand/orcaregiverwithin2businessdaysofdischarge
• Medicaldecisionmakingofhighcomplexityduringtheserviceperiod
• Face-to-facewithin7calendardaysofdischarge
Slide: Tools for Ensuring Smooth Transitions in Care
• Pre-encounter handoff: outlining the purpose of a visit, relevant clinical information, and requested referral relationship and timeline
• Caremapping:creatingavisualrepresentationofthepatient’scareteam membersincollaborationwiththefamilyanddiscussingtheirrolesand who-tolinesofcommunication
• Post-encounter handoff: development of an action item grid with the family outlining the overall care goal, task to be completed, who is responsible, timeline for completion, and contingency plan
• Careplan:acomprehensive,integrated,shared,anddynamicdocument thatincorporatesasummaryofmedicalissues,careteammembership, andprioritizedgoalsofcareandactionstoachievethem
Facilitator note:Demonstratetheuseof2ofthesetoolsinLucia’scase.
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 1Pediatric Care Coordination Curriculum 2nd Edition 37
Slide: Action Grid—Develop Care Plan Components for Lucia
Facilitator note: Haveparticipantslistcoreelementsofthecareplan.
Someideasarelistedbelow:LUCIACAREPLAN
Essential Fields/Components • Name • Dateofbirth • Insurance(primaryandsecondary) • Phonenumberandemergencycontactinformation • Parentorcaregivers’names • Diagnoses • Medications • Allergieswithdoses • Specialists’namesandphonenumbers • Hospitalizationsandsurgeries • Childoryouthstrengths • Familygoalsfortheirchild
Support Services • Equipment(ifapplicable,catheters,tracheostomies,gastrostomytubes,
wheelchair,orthotics,etc.) • Therapies(speech,PT,OT) • School/childcare/IEP • Homecareand/ornursingservices • Pharmacy • Mentalhealthagenciesandproviders • Dentalcare • Communityagencies • Transitioncareplanelements,ifapplicable
Secondary Elements • Pastmedicalhistoryandreviewofsystems • Communicationdevices • Homemodifications • Activitiesofdailyliving(challenges,toileting,hygiene) • Respite • SSI • Schoolinformation(grade,teacher,IEP,IFSP) • Feeding,diet,nutrition • Housingandtransportationneeds • Hearingandvisionservices
Alternative Medicine, Palliative Care
© 2019 Boston Children’s Hospital. All rights reserved.
Case-Based Learningcontinued
Module 4Pediatric Care Coordination Curriculum 2nd Edition 38
Works Cited
© 2019 Boston Children’s Hospital. All rights reserved.
AmericanAcademyofPediatricsCouncilonChildrenwithDisabilitiesandMedicalHomeImplementationProjectAdvisoryCommittee.Patient-andfamily-centeredcarecoordination:aframeworkforintegratingcareforchildrenandyouthacrossmultiplesystems.Pediatrics.2014;133(5):e1451–e1460
PondB,LambertM,VianoM,LambertL;Parent/ProfessionalAdvocacyLeague.(2012). Linkingmedicalhomeandchildren’smentalhealth:listeningtoMassachusettsfamilies. http://ppal.net/wp-content/uploads/2011/01/Medical-Home-Report.pdf.PublishedJune2012 Accessed May 16, 2019
StarmerAJ,SpectorND,SrivastavaR,etal.Changesinmedicalerrorsafterimplementationofahandoffprogram.N Engl J Med.2014;371(19):1803–1812
ZinielSI,RosenbergHN,BachAM,SingerSJ,AntonelliRC.Validationofaparent-reportedexperiencemeasureofintegratedcare.Pediatrics.138(6):e20160676
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