Clinical Research Coordinator II Medical College of Wisconsin Medical College of Wisconsin Milwaukee, Wisconsin, United States
Background: Complex Care Programs (CCP) offer care coordination and medical co-management to meet the needs of children with medical complexity (CMC). Our CCP added post-NICU CMC as a sub-population in 2014. Anecdotally, we observed that post-NICU CMC often spend a limited amount of time in the CCP.
Objective: Describe CCP usage by post-NICU enrolled CMC compared to CMC enrolled from other referral sources.
Design/Methods: Setting: CCP that provides inpatient/outpatient care coordination and consulting medical co-management to CMC. Hospital-based CCP in a tertiary center with a 70-bed Level IV NICU with >750 patients per year and no formal post-NICU care coordination program. Describe approach for post-NICU and all other CMC referred to the CCP and CCP discharges within 6 and 12 months of enrollment, 9/1/14-8/31/18. Analysis: Descriptive statistics reported.
Results: A CCP provider attends weekly NICU discharge rounds to identify patients predicted to meet CCP criteria and those families are invited for an initial CCP visit. Other CMC may be referred by any member of their care team including parents. During the study period 772 children were newly enrolled in the CCP, 220 post-NICU and 552 CMC referred through other sources. See Table 1. Reasons for discharge were: Deceased, Graduated (CCP team, primary care, and family agree CCP no longer needed), Lost to Follow-Up (>3 months of no response to attempted contact by CCP), Moved, Transitioned (to adult care, another care coordination program, or another hospital system), Withdrew (family requested to leave the CCP). Within one year of their enrollment, 32.3% of post-NICU enrollees and 16.3% of other enrollees were discharged from the CCP. Conclusion(s): Within a year of enrollment up to 20% of post-NICU CMC and their families no longer need or want the CCP, compared to 8% for other CMC. One benefit of CCP participation is long-term engagement with a care team that knows the child and family’s history, strengths, and needs. Perhaps a new short-term CCP model would be more appropriate to engage with post-NICU CMC and their families as they transition from the wraparound support of the 24/7 NICU environment, adjust to care at home, and establish outpatient care with a primary provider and specialists.
In the future we hope to develop and use a more objective screening tool to identify both post-NICU and other CMC who would benefit from the CCP.
Authors/Institutions: Sarah Johaningsmeir, Medical College of Wisconsin, Milwaukee, Wisconsin, United States; Tera C. Bartelt, Children's Hospital of Wisconsin, West Bend, Wisconsin, United States; Erin Sirovina, Medical College of Wisconsin, Milwaukee, Wisconsin, United States; Apryl Weed, Medical College of Wisconsin, Eden, Wisconsin, United States; Deborah Bartlett, Children's Wisconsin, Milwaukee, Wisconsin, United States; Amanda Pelock, Children's Wisconsin, Milwaukee, Wisconsin, United States; Timothy E. Corden, Medical College of Wisconsin, Milwaukee, Wisconsin, United States
