Petitgout, J. M., Werner, J. L., & Stewart, S. (2021). Pediatric Complexity Tool Best Practice Alert: Early Identification of Care Coordination for Children with Special Health Care Needs. Journal of Pediatric Health Care, 35(5), 485–490. https://doi.org/10.1016/j.pedhc.2021.04.010
Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Consultation Systems (Hospital), Quality Improvement,
Intervention Description: For more efficient and timelier enrollment into our care coordination program, we created a best practice alert within our electronic medical record to help overcome the challenges in timely identification of CSHCN. The best practice alert has helped us to provide care coordination benefits to our patients earlier in their hospital course. The purpose of this paper is to describe a quality improvement initiative to improve the early identification of CSHCN on hospital admission through the development of a best practice alert.
Intervention Results: The BPA was turned on in May of 2020. The BPA fired 259 times between May 2020 and February 2021. Of the total BPA activations, 22% (57) were accepted by a provider and resulted in a consult for care coordination. On further evalua- tion of the 22% compliant with accepting the BPA, we discovered that many providers were choosing to “snooze” the order or were writing in a comment stating that COC is not applicable for this patient. If the admitting physician “snoozes” the order, this merely suppresses the BPA for that specific provider for 1 hr. If any other providers enter the EMR during that same hour, they are presented with the BPA. If no other providers are in the chart and 1-hr passes, the original provider will see the BPA again once they sign into the patient’s EMR. There is currently no limit to the num- ber of times a BPA can be “snoozed” by a provider.
Our aim to achieve timely identification of CSHCN who may benefit from care coordination on admission was only partially met. Compliance of 22% of successful consults for COC after BPA activation suggests an opportunity for improvement in this process. In addition to providing more focused educational opportunities about the importance and benefits of the BPA, discussions with providers to learn about their reasons for not accepting the BPA also needs to occur. Evaluation of the timing of the BPA, number of times allowed to “snooze,” and other operational characteristics of the workflow will be evaluated. We will persist with a goal of initiating care coordination for > 50% of the CSHCN who meet the criteria on admission. Further improvements will be made to reach our quality improvement project goal to expedite care coordination and improve care for CSHCN during the hospital admission process.
This quality improvement process which enhanced our current pediatric complexity tool to better identify CSHCN on admission who may require care coordination services through the development of a BPA, will continue to need refinement and evaluation over time.
Further development and evaluation of the workbench reports will assist us in understanding additional benefits to connecting appropriate patients with care coordination. For example, analysis of timely enrollment into the program and readmission rate within 30 days is an important aspect to track. Ongoing evaluation and fine-tuning will help identify additional gaps in our care coordination system.
Conclusion: Classifying children with complex medical conditions according to the level of complexity can be complicated. Although experienced care coordination programs may be able to identify some patients who would benefit from these services, creating a complexity tool with a BPA in the EMR is helping a Midwestern children’s hospital streamline the process to increase sensitivity and specificity for CSHCN. Despite the tool’s limitations and the potential need for ongoing revisions, the usage of complexity tools and BPAs will become critical to target pediatric patient populations that have high usage of resources and services requiring the need for care coordination ongoing. Creating and imple- menting new ways to assist with the early identification of CSHCN requires new and innovative thinking to help achieve more comprehensive, individualized, and focused care.
CSHCN requires focused care coordination now and in the future. With further development of care coordination programs across the country and the development of identi- fication tools, including BPAs, we would hope to see a more streamlined connection for successful care coordination services for CSHCN. The traditional systems of care may not be fully meeting the needs of CSHCN. The coexistence of a care coordination program with a complexity tool to include a BPA for enrollment is an approach that is impor- tant in capturing the need for early services. The creation of this coexistence is essential for enhancing outcomes and providing a smooth transition from hospital to home. By identifying this specific patient population on admission, navigation of a complex and ever-changing medical system with the assistance of a care coordinator earlier can help maintain our commitment to improving the health and well- being of CSHCN.
CSHCN at our children’s hospital continues to benefit from COC and the care coordination team. The BPA is successful at identifying the potential beneficiaries of care coordination at an early stage, as identified by our recent audit; however, we will need to continue to refine the pro- cess. In addition, there will always be a need for the contin- ued presence of care coordinators at daily medical rounds and huddles to provide that consistent assessment and abil- ity to identify CSHCN who may not be acknowledged by an automated process. The definition of CSHCN is ever-chang- ing as well, and opportunities and strategies to identify those who will most benefit from care coordination will continue to evolve.
Study Design: The provided document does not explicitly state a study design for the quality improvement initiative described. The document describes the implementation of the initiative, the outcomes, and the ongoing evaluation and refinement of the process. Therefore, the study design is likely a quality improvement initiative or program evaluation, rather than a traditional research study with a specific study design.
Setting: The study was conducted at the University of Iowa Stead Family Children's Hospital in Iowa City, IA. The setting for the study was within the Care Coordination Division and Department of Nursing at the children's hospital.
Population of Focus: The target audience for the study is healthcare providers and administrators who work with children with special health care needs (CSHCN) in hospital settings.
Sample Size: The provided document does not explicitly state a sample size for the study. However, it does say that the best practice alert (BPA) tool (i.e. the intervention) was turned on in May of 2020 and fired 259 times between May 2020 and February 2021. Of the total BPA activations, 22% (57) were accepted by a provider and resulted in a consult for care coordination.
Age Range: The document does not explicitly mention a specific age range for the study. However, it does indicate that the BPA looks for required elements in the patient’s EMR on admission, and that one of the elements that trigger an inpatient BPA to fire included aged ≤ 18 years.
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