Transcript Complex Care_LaRagione_Zimmaro 11-5-15

Complex Care Does Not Have to
Equal Complex Transitions:
How to Help Make Transitions
Smoother
GWENN LARAGIONE, RN, BSN, CCM, CHPPN
BARBARA S ZIMMARO MSN, CRNP, CNPN

This lecture has no commercial
support to disclose

Gwenn LaRagione and
Barbara S Zimmaro have no relevant
financial relationships to disclose
Objectives

Identify at least three core principles in assessing the needs of a medically complex
pediatric patient during transitions in care.

Describe the importance in identifying the stakeholders involved during a transition of
a medically complex pediatric patient.

Identify at least three steps in the planning process of coordinating a transition of a
medically complex pediatric patient.

Describe the challenges and rewards experienced in transitioning a medically
complex pediatric patient.
Medically Complex Children
Children with:
 intense medical needs
 multisystem disease states
 complex medication regimens
Journal of American Academy of Pediatrics
Increasing Prevalence of Medically Complex Children in US Hospitals
Katherine H. Burns, MD, Patrick H. Casey, MD, Robert E. Lyle, MD,
T. Mac Bird, MS, Jill J. Fussell, MD, James M. Robbins, PhD, 2010
NHPCO Web site
Concurrent Care

On March 23, 2010, President Obama signed the Patient Protection
and Affordable Care Act into Law, with a new provision, Section
2302, termed the “Concurrent Care for Children” Requirement.
Concurrent Care
“A voluntary election of hospice care for a child cannot constitute a
waiver of the child’s right to be provided with, or have payment made
for, services that are related to the treatment of the child’s condition,
for which a diagnosis of terminal illness has been made.”
Medically Complex Children
Multiple specialists/providers
 Medical equipment providers
 Home Care Agencies
 Advocacy groups/agencies
 Transition across various health care and
community settings
 More than one payer
 Complex care coordination

Pediatric Care Coordination…

….is a patient-and family-centered,
assessment-driven, team-based activity
designed to meet the needs of children and
youth while enhancing the care giving
capabilities of the families. Care
coordination addresses interrelated medical,
social, developmental, behavioral,
educational and financial needs to achieve
optimal health and wellness outcomes.
Policy Statement: Patient-and Family-Centered Care Coordination: A Framework for Integrating Care for
Children and Youth Across Multiple Systems; From the American Academy of Pediatrics, 2015
Care Coordination

Is paramount in developing and fostering
partnerships across various settings and
communities

Enables the achievement of the triple aim:
-Better Care
-Better Health
-Lower Cost
Policy Statement: Patient-and Family-Centered Care Coordination: A Framework for Integrating Care for
Children and Youth Across Multiple Systems; From the American Academy of Pediatrics, 2015
Patient- and Family-Centered Care
American Academy of Pediatrics

Family-centered care is an approach to the planning,
delivery, and evaluation of health care that is grounded in
mutually beneficial partnerships among health care
providers, patients, and families.

Family-centered care is a respectful family/professional
partnership that honors the strengths, cultures, traditions, and
expertise that everyone brings to the relationship. Familycentered care is the standard of practice which results in
high quality services
Core Principles of Patient and FamilyCentered Care
AAP – 1/2012
Listening and respecting the child and
family
 Ensure flexibility
 Sharing complete, honest and unbiased
information
 Providing and/or ensuring formal and
informal support
 Collaboration with patients and families at
all levels of health care
 Recognizing and building on the strengths
of individual children and families

Times of Transition

Change in medical condition

Change in location

Change in caregivers

Change in goals

What is the central issue?

Why is a change needed?

Who are the stakeholders?

When: Timeline/Venue(s)?

What are the steps needed to
accomplish the goal?
Stakeholders:
Family
Extended
Family/Friends
Medical Team
Faith
community
Nursing
Agency
Child
Transport
EMS
LTC facility
Hospice
School District
Local Hospital
Planning…and more planning!
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Pre-meeting of primary stakeholders
(face to face or conference call)
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Describe anticipated changes and
walk-through possible outcomes
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Explicitly name the person responsible for
each task

Checklists
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Anticipate imperfection
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Plan for ongoing, regular
communication
Checklists
Patient/Family Discussions
-Who’s the decision maker
-What are the goals of care
-What other family members should be
included in discussions
-Identify ongoing communication schedule
-Identify the best way/time to reach decision
maker
Checklist
Initial Tasks
-Initiate referrals
-Arrange meet and greets; schedule tours
-Notify primary pediatrician and specialists
-Determine date/time of transfer
-Confirm correct address (home, facility)
-Notify payer/s; obtain authorizations
-Schedule transport
-Complete admission forms prior to discharge if
possible
Checklist
Medications
-Review patients medications and schedule
-Are there any compound meds
-What medications does the patient already have,
what scripts are needed
-Who will be providing the medications
-Do any medications need prior authorization
-Have all medications filled prior to transport
-IV medications
Checklist
Medical Equipment
-Are they reproducible in the home/facility
-Identify what is already in the home and make
sure it’s in working condition; is there enough
oxygen
-Does home need an inspection for electricity
-Have equipment delivered and set up prior to
discharge
-Is back up equipment needed
Checklist
Prior to Discharge
- Complete admission forms (home care, hospice,
facility, etc) prior to discharge/transfer
- Complete DNR/POLST forms if applicable
- Develop individualized plan of care with
participation of patient/family/providers
- Identify an ongoing communication schedule
Checklist
Preparing the Patient/Family
-For the transition
-For the uncertainties
-Arrange a discharge/transfer
family meeting
Checklist
Psychosocial Support
-Access need for spiritual support
-Access need for sibling support
-Offer memory making/legacy activities
-Offer bereavement support
-Determine if family informed extended family
of the plan
Checklist
Sign-out
- Physician to Physician
- Nurse to Nurse
- Social worker to Social worker
- Chaplain to Chaplian
Transitioning off Hospice

Celebrate!!!!!
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Give plenty of notice

Notify primary physician

Notify specialists
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Transition payer for DME or switch to a contracted provider
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Transition scripts to a retail pharmacy
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Check what co-pays will be
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Constant communication
Challenges
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Complex coordination

Financial Resources

Physical Space
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Language
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Cultural awareness

Time!
Rewards
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The best in family and
child centered care

Provides meaningful roles
for invested stakeholders

Enables the achievement
of the triple aim:
-Better Care
-Better Health
-Lower Cost