1. Programs for Children with Complex Chronic Conditions at Brenner Childrens Hospital Savithri Nageswaran MD,MPH September 12 th 2012

2. PEDIATRIC ENHANCED CARE PROGRAM Pediatric Enhanced Care Team (PECT) Community Pediatric Enhanced Care Team (CPECT) Community Pediatric Enhanced Care Team (CPECT-Extend) Collaborative Care Service

3. Medical Neighborhood: Healthy Child Medical Home Dentist Child & Family AHRQ White Paper: Medical Neighborhood

4. Medical Neighborhood: Child with a Chronic Condition Medical Home Specialist Dentist Pharmacy Child & Family AHRQ White Paper: Medical Neighborhood

5. Medical Neighborhood: Child with Complex Chronic Condition Medical Home Specialist 1 Specialist 2 Specialist 3Specialist 4 Specialist 5 Pharmacy Home Health DME Companies Inpatient Care Schools Family Support Child & Family AHRQ White Paper: Medical Neighborhood

6. Pediatric Enhanced Care Program PECT: pediatric palliative care in the hospital for seriously ill children – 1 FTE nurse & 0.3 FTE physician – Funding: Duke Endowment start-up funds; now Brenner Childrens Hospital CPECT: care coordination for children with CCC in Forsyth County – 0.5 FTE nurse, 0.05 FTE project director, 0.1 research associate – Funding: Maternal & Child Health Bureau CPECT-Extend: Extension of CPECT to Yadkin, Surry, Stokes, Davie, Wilkes counties – 0.75 social worker, 0.05 project director & 0.1 research associate – Funding: Maternal & Child Health Bureau Collaborative Care Service (CCS): collaboration between multiple sub- specialists in the care of children with undiagnosed complex conditions – 0.5 FTE nurse & 0.15 physician – Funding: Brenner Childrens Hospital

7. Children with CCC at Brenner Childrens Hospital (FY 2009 PECT Patient Statistics) 14.71 days (All children in BCH 6.6) ALOS 40 days Average hospital days/ patient 179, 209, 216, 222, 222 5 largest hospital days 3 Average # of Discharges/Patient 61.6% Percent of Patients with Multiple Discharges 7, 8, 9, 11, 13 5 largest number of discharges Medical Center Strategic Planning ; January 2010

8. Children with CCC at Brenner Childrens Hospital (FY 2009 PECT Patient Statistics) UtilizationPECT (%)* 3-Day Readmission Rate 6.9 % 7-Day Readmission Rate 11.9 % 14- Day Readmission Rate 21.1 % 30- Day Readmission Rate 35.6 % ED Visits within 7-days of Discharge 18 12% *Medical Center Strategic Planning ; January 2010

9. Children Enrolled in CPECT & CPECT/E (n=56) All <18 (one now older than 18) All chronic condition Complexity upon enrollment – >5 subspecialists/services 46 yes, 4 no, 2 missing – >2 technology 29 yes, 19 no, 4 missing – >3 hospitalization/months 14 yes, 34 no, 4 missing – >30 days hospitalized/6 months 20 yes, 28 no, 4 missing

10. Care Coordination Needs Factors that Determine Care Coordination Needs: Complexity of the condition Fragmentation of care Family capacity - AHRQ: Care Coordination Atlas 2011

11. Child & Family Medical Home Speciali st Dentist Pharmac y Care Coordination Needs: Complexity Medical Home Specialist 1 Specialist 2 Specialist 3Specialist 4 Specialist 5 Pharmacy Home Health DME Companies Inpatient Care Schools Family Support Child & Family

12. Care Coordination Needs: Low Fragmentation Medical Home Specialist 1 Specialist 2 Specialist 3Specialist 4 Specialist 5 Pharmacy Home Health DME Companies Inpatient Care Schools Family Support Child & Family

13. Care Coordination Needs: High Fragmentation Medical Home Specialist 1 Specialist 2 Specialist 3Specialist 4 Specialist 5 Pharmacy Home Health DME Companies Inpatient Care Schools Family Support Child & Family

14. Care Coordination Needs: Family Capacity

15. Care Coordinator's Contacts with Children with CCC & their Families

16. Care Coordination of Children with CCC

17. Gaps in Coordinated Care of Children with CCC

18. Community Team to Coordinate Care of Children with CCC

23. PEDIATRIC ENHANCED CARE PROGRAM Pediatric Enhanced Care Team (PECT) Community Pediatric Enhanced Care Team (CPECT) Community Pediatric Enhanced Care Team (CPECT-Extend) Collaborative Care Service New: Interdisciplinary clinic for children with CCC