1. Spanning the Continuum of Care Chuck Willson MD September 13, 2012

2.  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

3.  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

5.  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

6.  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

7.  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

8.  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)

9. Year

10. 36% decrease in 30 day re-admits in 2010 as compared to 2008 Number of patients with a 30 day readmission: 2008 – 5 patients, 2009 – 18 patients, 2010 – 14 patients

12. 11% Reduction in Visits after C5 Intervention 55% Reduction in Hospitalizations after C5 Intervention

13. 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

14.  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)

15.  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