Preventing or accelerating emergency care for children with complex healthcare needs

Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.
Archives of Disease in Childhood (Impact Factor: 2.91). 02/2008; 93(1):17-22. DOI: 10.1136/adc.2007.117960
Source: PubMed

ABSTRACT A subgroup of children with special health care needs (CSHCN) have chronic and complex medical conditions and frequently attend the emergency department (ED). Some of these ED visits could be prevented through appropriate clinician advice or, if an ED visit is unavoidable, the management time could be decreased. We set out to determine whether an ED-based advice and coordination programme was feasible and could prevent or accelerate ED care for these patients. METHODS, SETTING AND PATIENTS: We identified CSHCN who frequently attended the ED at a large tertiary children's hospital. These patients were enrolled in an ED-based coordination programme, the Accelerated Care through Emergency (ACE) programme providing 24-hour mobile-phone access to experienced ED nurses. We prospectively tracked usage patterns and determined the rate of ED visits after receiving phone advice and the waiting time for patients to be seen in ED. Parental satisfaction and cost of the programme were also assessed.
After a pilot phase in 2002, enrollment in the programme increased from 125 in 2003 to 220 patients in 2006. Patients had a broad range of medical conditions. All had two or more and up to 22 medical services involved in their care. 80% of patients used a technical device or implant. Phone calls increased from an initial average of 31 per month in 2003 (0.24 calls per participant) to 66 per month in 2006 (0.3 calls per participant), 60% of which were after hours. The percentage of ED reviews per phone call dropped from an initial 74.2% (95% CI 55.2%-88.1%) in 2003 to 50.0% (95% CI 37.4%-62.5%) in 2006 (p = 0.02). However, decreases in ED visits and admissions as a percentage of enrolled patients and as a percentage of phone calls to ACE staff were not statistically significant. Mean waiting time for enrolled patients remained below 30 minutes. Parent satisfaction with the programme was rated 8.3 on a 0-10 scale (0 meaning poor, 10 meaning excellent). The approximate cost of the programme per child was AU$750 (292 pounds sterling) per year.
We have developed a coordinated approach towards the provision of healthcare for a group of families with diverse severe chronic medical conditions who frequently present to the ED. Through a comprehensive programme including the development of patient-care plans, care coordination and 24-hour mobile-phone access we were able to enhance families' capacities to manage their children's conditions in the community.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Children with developmental disabilities (DDs) have higher rates of emergency department use (EDU) than their typically developing peers do. This study sought to elucidate the relationship between EDU frequency and access to a comprehensive medical home for children with DD.
    Pediatric Emergency Care 07/2014; DOI:10.1097/PEC.0000000000000184 · 0.92 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Integrated care has important implications for children with medical complexity (CMC) who rely on care and service delivery involving multiple providers in different places over time.Most studies describing complex care programmes focus on the effectiveness of care co-ordination rather than the process of system integration. This pilot study explores the implementation process of the Integrated Complex Care Model: a voluntary partnership between acute, rehabilitative and community care aimed at system integration through a key worker model to improve care co-ordination for CMC. Methods This descriptive study used qualitative analyses and syntheses to explore the process of inter-organizational collaboration under ‘real-life’ circumstances.Multiple methods and sources of data were gathered to support triangulation in understanding of enablers and barriers to model implementation. Forty hours of meeting minutes and administrative databases housing patient records were reviewed. Baseline demographic information was available for 23 families, including child health-related quality of life and healthcare utilization. A subset of 12 parental caregivers and 21 additional key informants participated in individual interviews or focus groups. Findings are presented using King and Meyer’s description of system integration and care co-ordination. Results Model enablers included dedication, timing, leadership and electronic care plan use/ communication among key workers, families and health providers. Barriers included assumptions about partner organizations, differing organizational structures and client information systems, constrained project resources and limited engagement of primary care. Parents perceived an electronic care plan as a facilitator of timely and effective care for CMC across multiple settings. Conclusions At a systems level, the integrated model fostered collaboration between partner organizations. At a family level, development of inter-organizational management structures and communication platforms; provision of adequate resourcing; and increased engagement of primary care may enable high level organizational integration aimed at improved care co-ordination for CMC.
    Child Care Health and Development 01/2013; DOI:10.1111/cch.12122 · 1.83 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To understand the pattern of utilization of ambulatory care by parents of children with special health care needs (CSHCN) and to explore parental challenges in coping with health maintenance of their infants after discharge from a neonatal intensive care unit (NICU). CSHCN require frequent utilization of outpatient ambulatory clinics especially in their first years of life. Multiple barriers are faced by families in disadvantaged populations which might affect adherence to medical referrals. Our study attempts to go beyond quantitative assessment of adherence rates, and capture the influence of parental agency as a critical factor ensuring optimal utilization of healthcare for CSHCN. A prospective, mixed-methods, cohort study followed 158 Jewish and Bedouin-Arab infants in the first year post discharge from NICU in southern Israel. Rates of utilization of ambulatory clinics were obtained from medical records, and quantitative assessment of factors affecting it was based on structured interviews with parents at baseline. Qualitative analysis was based on home visits or telephone in-depth interviews conducted about 1 year post-discharge, to obtain a rich, multilayered, experiential perspectives and explained perceptions by parents. Adherence to post-discharge referrals was generally good, but environmental, cultural, and financial obstacles to healthcare, magnified by communication barriers, forced parents with limited resources to make difficult choices affecting utilization of healthcare services. Improving concordance between primary caregivers and health care providers is crucial, and further development of supportive healthcare for CSHCN in concordance with parental limitations and preferences is needed.
    Maternal and Child Health Journal 01/2014; 18(8). DOI:10.1007/s10995-013-1427-2 · 2.24 Impact Factor