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

   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

   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

    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

    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

    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

    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)

45 40 35 30 25 20 15 10 5 0 41 31 2008 Year 2009 33 2010

35% 30% 25% 20% 15% 10% 5% 0% 33% 2008 29% 21% 2009 Year 2010

80% 70% 60% 50% 40% 30% 20% 10% 0% 73% 2008 67% 54% 2009 Year 2010

300 250 200 150 100 50 0

11% Reduction in Visits after C5 Intervention

71 63 ED visits

Before 55% Reduction in Hospitalizations after C5 Intervention

252 113

After

Hospitalizations

Reduction in Visits/Stays Average Total Cost Per Visit / Inpatient Stay Overall Total Cost Avoidance ED Visits: Hospitalizations: 8 139 $515 $47,277 Total program cost avoidance from 10/1/2008 thru 12/31/2010 = $6,575,623 $4,120 $6,571,503

   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)

    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