Comprehensive Transitional Medical Home for
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Transcript Comprehensive Transitional Medical Home for
Comprehensive Transitional
Medical Home for Medically
Fragile Infants: Redesigning the
Model for Post-discharge Care
Ricki F. Goldstein MD
Professor of Pediatrics
Director, High-Risk Infant Follow-up Program and
Special Infant Care Clinic
Division of Neonatology
Duke University Medical Center
The Problem
Extremely premature and critically ill term
infants
discharged home with a complex mix of
pulmonary, cardiac, gastrointestinal, endocrine
and neurologic problems
Multiple medications
Complicated feeding regimens
Special equipment
Limited insurance coverage for nursing care
Few pediatricians and family medicine physicians
have the training, experience, and availability to
optimally care for these fragile infants during their
most vulnerable first year of life.
Present system of care
Frequent lack of continuity of primary care
house-staff clinics
large pediatric and family medicine practices
health departments
Multiple subspecialty clinic appointments scheduled
soon after discharge
Frequent visits to the emergency room for acute
problems (triaged at night)
Inconsistent quality of community case management
Poor communication, fragmentation and/or
duplication of care
Consequences
Delayed or ineffective care
acute illnesses or complications develop into
severe, even life-threatening problems
feeding and nutritional difficulties lead to failure to
thrive
Frequent use of emergency room
Evaluated by physicians unfamiliar with neonatal
problems
Multiple visits with eventual admission
Rehospitalization
Often straight to PICU
Solution
Comprehensive Transitional Medical Home
(TMH)- funded by The Duke Endowment
Tertiary care medical center team
Health care providers with special training,
experience, availability and commitment
Medical follow-up during “transitional” period
between neonatal hospitalization and care by
general pediatric medical home
Chronic medical problems more stable
Growth and nutrition established
Parents more comfortable and confident
Goals of TMH Home Program
Maximize long-term medical and developmental
outcomes
Comprehensive medical care
Improved community case management
Decrease overall cost of post-discharge medical
care
Educate well-child care providers in the longterm care of infants with complex medical
problems
Research
A large, single-center randomized trial of
comprehensive care for preemies in Dallas
Well-baby care
Acute and chronic illnesses and complications
Experienced physicians and nurse practitioners,
Available 5 days/week in clinic and by pager 24/7
Results
Substantially reduced life-threatening illnesses
resulting in death or admission to a PICU
Reduced cost of post-discharge care during the
first year of life.
Broyles et al JAMA 2000;284:2070-6.
Research
Children’s hospital-based multidisciplinary
clinic in Kansas
provides comprehensive and coordinated care for
medically complex children
ensures that each patient receives all necessary
medical, nutritional, and developmental care
Results
Significant decrease in total Medicaid costs
Casey PH et al. Arch Pediatr Adolesc Med. 2011;165(5):392-398.
Proposed TMH model of care
Immediate medical follow-up within 1-3 days after
discharge.
Co-management of acute illnesses related to
neonatal problems (ability for next day visit)
Surveillance and treatment of chronic medical
problems with coordination of consulting subspecialist visits when needed.
Ongoing feeding and motor evaluations and
arrangement for intervention services
Proposed TMH model of care
24/7 pager availability, by experienced
physician or nurse practitioner familiar with
the babies' medical problems
Parents to call with questions and acute problems
Primary care provider when seeing child
ER physicians
Admitting hospital
Eligibility criteria
Extreme prematurity:
Less than or equal to 26 weeks gestation at birth
Chronic medical problems in premature or term infants
Chronic lung disease of infancy
Feeding problems (e.g. G-tube, NG tube, severe
gastroesophageal reflux, dysphagia)
Surgical necrotizing enterocolitis, other short-gut syndrome
Severe respiratory failure
ECMO
Congenital diaphragmatic hernia with PPHN
Congenital heart disease requiring delayed or multi-staged
correction (in future)
Severe brain injury
Hypoxic ischemic encephalopathy
Severe intraventricular/intracranial hemorrhage
Periventricular leukomalacia, neonatal stroke
Evaluation of TMH Program
Acute illnesses (type and how treated)
Growth during first year
Timeliness of immunization administration
including Synergis and Flu shots
Emergency room visits (reasons and outcome)
Sub-specialty clinic visits (type and number)
Rehospitalizations, including but not limited to
PICU stays (reasons and length of stay)
Early intervention services (type, when initiated)
Evaluation of TMH Program
Nature of phone calls received from parents
and the outcome of advice given.
Nature of phone calls received from WCC
providers or outside ER’s and the outcome
of advice given.
Neurodevelopmental outcome at 9-12
months of age
Cost of all medical care during the first year
after discharge (including primary care and
specialty visits, acute care, hospitalizations,
ER visits, medications, etc)
Measureable goals
Improve continuity of care and decrease
duplication of services
compare number of different well-child care and subspecialty providers over first year
Decrease emergency room visits
Decrease number of and length of stay
during rehospitalizations to Duke or other
hospital
Decrease PICU admissions and length of
stay
Measureable goals
Improve medical and developmental
outcomes of our most medically fragile NICU
(and eventually PCICU) graduates.
Decrease post-discharge cost to third party
payers for NICU and PCICU graduates
medically fragile infants during the first year
of life.
Present and future partners
North Piedmont Community Care Network
Local post-discharge visits and early coordination
of care
Initial communication with case managers in other
counties
North Carolina Children’s Accountable Care
Collaborative
Hospital based case manager to serve as liaison
to all medical providers and community agencies
Work closely with TMH program to improve
outcomes and decrease cost of care for Medicaid
patients.