Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Quality Improvement, Shared Plans of Care

Intervention Description: The intervention described in the study is the Compass Care Program, which is a consultative complex care program designed to address the needs of children with medical complexity (CMC) receiving specialty care at the institution. The program provides complex care consultation for children across inpatient and outpatient settings, with the goals of proactively coordinating care, improving the quality of care for CMC, and enhancing caregiver satisfaction . The program aims to achieve these goals through a multidisciplinary approach that involves care coordination, specialized services, and ongoing support for the patients and their families.

Intervention Results: Participants had significant decreases in hospital admis- sions per patient month, length of stay per admission, hospital days per patient month, and charges per patient month following enroll- ment (P<0.01) without a tandem increase in readmissions within 7 days of discharge. There was no statistically significant difference in ED visits. Caregiver satisfaction scores improved in all domains.

Conclusion: Participation in a consultative complex care program can improve utilization patterns and cost of care for CMC, as well as experience of care for patients and families.

Study Design: The study utilized a pre-post design to evaluate the impact of the Compass Care Program for children with medical complexity (CMC) and their families. It compared baseline data for each patient from the 12 months before enrollment with post-enrollment data for all months after enrollment . This design allowed for the assessment of changes in utilization metrics and caregiver satisfaction after program enrollment.

Setting: The study was conducted in a tertiary care setting. The Compass Care Program, a consultative complex care program for children with medical complexity (CMC) and their families, was implemented across inpatient and outpatient settings within the tertiary care institution. This indicates that the program was designed to address the complex medical and social needs of CMC in both the hospital and outpatient care settings.

Population of Focus: The target audience for the study includes healthcare professionals, administrators, and researchers involved in the care of children with medical complexity (CMC) and their families. Specifically, pediatricians, pediatric specialists, hospital administrators, and researchers interested in complex care programs, care coordination, and improving outcomes for CMC would find the study relevant. Additionally, professionals and organizations involved in the development and implementation of consultative complex care programs in tertiary care settings may also benefit from the insights provided in the study.

Sample Size: The study enrolled 105 new patients into the Compass Care Program between June 1, 2015, and September 1, 2017. This sample size represents the population of children with medical complexity (CMC) who were enrolled in the program during the specified time frame.

Age Range: The study reports that at the time of enrollment, roughly half of the patients were between 0 and 1 year of age, while over 90% of patients were 9 years of age or younger.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Nurse/Nurse Practitioner, Shared Plans of Care

Intervention Description: To address the problem and alleviate burden for families, the Comprehensive Cerebral Palsy Program implemented a nurse‐led comprehensive interdisciplinary team approach to provide optimal care coordination to patients and families, using an Integrative Holistic Care Plan (IHCP). During an annual 3–4 hour Comprehensive CP Clinic appointment, a team of specialists meets with the family, and a holistic, evidence‐based plan of care is developed. The family‐centered care plan includes summaries of each discipline's plan of care with individualized goals, recommendations, and evidence‐based outcomes. After the visit, the plan of care is communicated with the family, primary care provider, and other community provi- ders to ensure continuity of care.

Intervention Results: Early in the program and electronic IHCP development stage, clinical, and financial outcomes were improved. In addition to significant cost savings, family satisfaction surveys showed continuous improvement in the areas of access, com- munication, and coordination of care.

Conclusion: Overall, the quality, effectiveness, and efficiency of care in the Comprehensive Cerebral Palsy Program, using the Integrative Holistic Care Plan, has resulted in improving health outcomes, decreasing cost, and increasing satisfaction of our CP patient population with complex needs. The data on reduced healthcare utilization, and improved family satisfaction support this conclusion. Based on the program success, additional state level funding to further enhance care coordination services and to formalize collaborations with Public Health Nurses from our catchment area was awarded and the program achieved NCQA Patient Centered Specialty Care Recognition.

Study Design: The article does not describe a specific research study with a traditional study design. Instead, it presents an original article detailing the development and implementation of an intervention, the Integrative Holistic Care Plan (IHCP), in the context of the Comprehensive Cerebral Palsy Program. The article discusses the implementation of the nurse-led comprehensive interdisciplinary team approach to provide optimal care coordination to patients and families, using the IHCP. Therefore, the article focuses on the description and outcomes of the implemented intervention rather than a traditional research study design.

Setting: Comprehensive Cerebral Palsy Program, Nationwide Children's Hospital, Columbus, Ohio

Population of Focus: The target audience for the study includes healthcare professionals, particularly those working in interdisciplinary clinics and caring for children and adults with cerebral palsy. This may include nurses, physicians, therapists, social workers, and other providers involved in the care of individuals with cerebral palsy. Additionally, the study may be of interest to healthcare administrators and policymakers involved in the development and implementation of care coordination programs for individuals with complex healthcare needs.

Sample Size: We have previously reported on the initial experience of 131 patients who received care in the Comprehensive CP Program during the first year of operation.

Age Range: The article does not describe a specific study with a defined age range but does appear to be child focused.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Shared Plans of Care

Intervention Description: The shared plan of care (SPoC) intervention described in the study is a care coordination tool designed to support children with special healthcare needs (CSHCN) and their families. The SPoC is a comprehensive care coordination document that focuses on patient and family goal setting. It is stored on an accessible, secure platform where healthcare information for CSHCN can be accessed by providers as well as families.

Intervention Results: Our results showed a decrease in primary care visits, hospitalizations, and ED visits for CSHCN after SPoC implementation, though only primary care visits reached significance. Mental health care visits were specifically found to decrease by 39% following employment of SPoC.

Conclusion: The use of SPoCs in CSHCN had a positive impact on healthcare utilization suggesting widespread use of this tool improved care coordination in this population.

Study Design: The study design is a retrospective observational study. The study analyzed data collected from electronic medical records (EMR) of children with special healthcare needs and mental health conditions who were seen in the Division of Child and Community Health’s Regional Centers in 2016. The study compared healthcare utilization outcomes before and after the implementation of shared plans of care (SPoC) as a care coordination tool. The study used statistical analysis to evaluate the impact of SPoC implementation on healthcare utilization outcomes, including the number of inpatient hospitalizations, emergency department visits, and primary care and outpatient psychiatry visits.

Setting: The setting for the study was the Division of Child and Community Health’s Regional Centers in Iowa.

Population of Focus: Who is the target audience for the study?

Sample Size: The study included a total of 15 subjects in the analysis.

Age Range: The study included children less than 18 years of age.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Shared Plans of Care

Intervention Description: The intervention described in the study involved a care coordination model using a family-centered, goal-oriented Shared Plan of Care (SPoC) with a cohort of children with complex neurodevelopmental disorders. The intervention included previsit assessments, planned care visits, SPoC development, and 6-month care coordination. The study aimed to explore family outcomes associated with the implementation of this care coordination/SPoC intervention.

Intervention Results: empowerment, and worry. Times 1 and 2 survey data were collected from a total of 70 families. Results: Analysis shows significant improvement in care coordination access, SPoC use, goals achieved, needs met, family empowerment, and reduced worry. There was no significant change in family-professional partner- ships and reported SPoC use.

Conclusion: Findings provide preliminary evidence that a care coordination model using a family-centered, goal-oriented SPoC is a feasible and effective approach with a cohort of children with complex neurodevelopmental disorders and is associated with improved family outcomes. Replication studies are warranted and should include a control group, prolonged time period, additional validated outcome measures, and measurement of costs and professional impact.

Study Design: The study utilized a pre-post intervention design to evaluate the effects of a care coordination intervention with children with neurodevelopmental disabilities and their families. This design involved collecting data from participants at two time points: Time 1 and Time 2, allowing for the assessment of changes before and after the intervention.

Setting: The study was conducted in a children's hospital ambulatory care setting in Indiana.

Population of Focus: The target audience for the study includes healthcare professionals, researchers, and organizations involved in the care of children with neurodevelopmental disabilities and their families. Additionally, policymakers and stakeholders interested in improving care coordination and outcomes for children with complex neurodevelopmental disorders may also find the study relevant and informative.

Sample Size: The final study sample included 70 participants with complete data at Times 1 and 2

Age Range: These participants were children aged 2 to 10 years.

Intervention Components (click on component to see a list of all articles that use that intervention): Care Coordination, Collaboration with Local Agencies (Health Care Provider/Practice), Shared Plans of Care

Intervention Description: This report will describe a care support project that delivered shared plans of care to providers and families of children with medical complexity. This program was built around carefully constructed care support teams where each member had clearly defined roles and responsibilities. The teams worked collaboratively to improve provider communication, create SMART (Specific, Measurable, Assignable, Realistic, and Timely) goals, and perform task tracking. This process created a scaffolding to support community physicians, allowing patients to remain in their local medical homes and to access services closer to home and reducing hospital admissions and emergency room overutilization.

Intervention Results: We found a statistically significant decline in the number of hospital admissions and mean length of stay—38% (P = .00056) and 43% (P =.041). We did find emergency room visits decreased by 14%, yet this was not statistically significant (P = .1455; Table 4). While we do not have a control group, we can say that our results mirrored the results of the CARE study that had a sample size more than 20 times the size of ours.

Conclusion: The 4C project, a multidisciplinary approach offering care support to CMCs, improves key measure of health outcomes. We described a process that outlines the roles and responsibilities of each team member in a care coordination team for CMC’s. Each team cared for a caseload of 100 very complex families, which mirrored the experience of the CARE study. Systems undergoing health transformation will need to consider investing in teams and information systems that can support complex care coordination.

Study Design: The study design is not explicitly stated in the article. However, the article describes the experience of implementing the Consultative Collaborative Coordinated Care (4C) program in two small pediatric programs and the outcomes of the program. The study evaluated the program's outcomes, including key measures of health outcomes, and compared them to the results of the Coordinating All Resources Effectively (CARE) study.

Setting: The setting for the study was two small pediatric programs created by the Consultative Collaborative Coordinated Care (4C) program. The 4C program was funded by the Center for Medicare and Medicaid Innovation award program from 2013 to 2017 and was a care support project within two pediatric hospitals that delivered shared plans of care (SPOC) and care coordination for children with medical complexity (CMC). The two pediatric hospitals were located on opposite sides of Massachusetts.

Population of Focus: The target audience for the study includes healthcare professionals, pediatricians, nurses, and other care providers involved in the care of children with medical complexity (CMC). Additionally, policymakers, administrators, and organizations involved in the development and implementation of care coordination programs for children with complex medical needs would also find the study relevant. T

Sample Size: The sample size of the study involved a total of 335 participants. However, a specific subset of this sample, consisting of 205 participants, was used for the analysis and reporting of the study's outcomes and results.

Age Range: The study did not specify a specific age range for the participants. However, the study focused on children with medical complexity (CMC), which typically includes children with chronic and complex medical conditions that require ongoing care and management. The age range of children with medical complexity can vary widely, from infancy to adolescence.