PDF《Sharing炉he烫are爋f?》

Sharing?the?Care?of? your?Complex?Patients June?9,?2015 Speakers ? CCP,?Complex?Care?Program? C Dr.

?Karen?Fratantoni? ? POCC,?Pediatric?Perioperative?Care C Dr.?Anjna?Melwani?and?Dr.?Sonaly?McClymont ? HELP,?Hospitalist?Consult?Service? C Dr.?Miriam?Bloom ? PANDA?Palliative?Care?Team? C Dr.?Melanie?Anspacher June?3,?2015 Learning?Objectives ? Define?the?continuum?of?care?services?available?for? children?with?medical?complexity?at?CNHS ? Identify?referral?criteria?and?process?for?CCP,?POCC,? HELP?to?PANDA?Palliative?Care Pediatric? Patient? Population CSHCN CMC Children with Medical Complexity (CMC) 0.4%?children 11%?health? care?charges 24%?hospital? charges Neff?JM,?Sharp?BL,?Popalisky J,?Fitzgibbon?T.??Using?medical?billing?data?to?evaluate?chronically?ill?children?over?time.??J? Ambul Care?Manage.?2006;

29(4):283\290. (Cohen,?E.,?Kuo,?D.?Z.,?Agrawal,?R.,?Berry,?J.?G.,?Bhagat,?S.?K.?M.,?Simon,?T.?D.,?&

?Srivastava,?R.?(2011).?Children? with?medical?complexity:?an?emerging?population?for?clinical?and?research?initiatives.?Pediatrics,?127(3),?529C 538) Our?patient FG?is?an?9?year?old?male?with??the?following?diagnoses: \ Neonatal?HIE \ Global?developmental?delay? \ Spastic?quadriparesis \ Seizure?disorder \ Temperature?instablility \ Central?precocious?puberty \ Chronic?lung?disease?with?baseline?oxygen?requirement?of?1/4?L \ Dysautonomia \ Oromotor dysfunction \ GERD? \ GJ?tube?dependence He?is?on?17?medications. He?is?followed?by??the?following??7?pediatric?subspecialists:?Cardiology,?Pulmonary,? Neurology,?PMNR,?GI,?Endocrinology,?Neurology. Due?to?his?care?coordination?needs,?his?community?primary?care?pediatrician?referred? him?to?the?Complex?Care?Program.? What?is?the?Complex?Care?Program? ? Developed?in?2002?as?a?consultative\only?model ? Provide?ongoing?medical?care?coordination?between?visits?including? communication?with?family,?primary?care?providers,?and?specialists?based? on?the?needs?of?the?family ? In?2011,?Complex?Care?was?integrated?into?primary?care?services?in?the? Children'

s?Health?Center,?the?largest?health?center?within?the?Goldberg? Center?for?Community?Pediatric?Health?at?Children'

s?Hospital.? ? Provide?a?patient?and?family\centered? Medical?Home ?for?children?and? youth?with?special?health?care?needs.? ? This?integrated?model?allows?us?to?provide?both?primary?care?and? consultative services?to?children?with?complex?chronic?conditions. What?can?Complex?Care?offer? ? Provide?comprehensive?care?coordination?through?a?team?approach?that? includes?physicians,?nurse?case?management,?parent?navigators,?and?social? work?services?provided?in?two?(2)?distinct?formats. 1. Established?Community?PCP: ? CCP?Physician?sees?the?patient?and?family?every?4\6?months?for?care?coordination ? Care?team?provides?continual?care?coordination?between?CCP?visits 2. For?those?without?a?PCP,?we?will?provide?primary?care?including: ? Well?Child?Care ? Urgent?Care ? All?CCP?care?coordination?services What?can?Complex?Care?offer? ? Medical?management?of?patients? with?complex?medical?needs ? Work?collaboratively?with?primary? care?provider,?family,?specialists,? therapists,?home?care?providers,? and?other?members?of?the?care? team ? Help?families?negotiate?the? healthcare?system?and?provide?a? link?to?community?resources ? Create?written?care?plans?with?the? family?to?share?with?the?primary? care?provider June?3,?2015 Social? worker specialists nurses therapists school home? nursing case? manager Parent? Navigator Patient? &

? Family PCP?+?CCP Who?is?eligible? ? Child?is?medically?complex?and?requires?intensive?hospital?or? community\based?service?needs,?has?two?or?more?chronic?conditions ? Followed?by?multiple?specialists?often?within?the?Children'