A Qualitative Study of Family Caregiver Perceptions of High-Quality Care at a Pediatric Complex Care Center

Qualitative evaluation of a hospital-inpatient service for children with medical complexity

OBJECTIVE

To explore the experiences and perceptions of parents and professionals of a hospital-inpatient service for children with medical complexity (CMC).

DESIGN

Semi-structured qualitative interviews with parents of CMC and healthcare professionals from one hospital site in England. Data were analysed using thematic analysis.

FINDINGS

Nine parents and 15 healthcare professionals participated. Two overarching themes were developed: (1) The service is an anchor for families and professionals and (2) The service is not a panacea. Participants valued the single point of contact for families and professionals involved in the child's care during hospital stays. Families felt heard, supported and involved in their child's care with the holistic needs of the child and family centre stage. Unclear boundaries around the role of the service and limited capacity of the team were key challenges. Professionals and families described a cliff edge for many families post hospital discharge.

CONCLUSION

A hospital-inpatient service for CMC can improve care coordination and discharge planning and help build strong relationships with parents so that they feel listened to and supported. Holistic services like this need clear boundaries and remits, as there is danger of 'mission creep'. A hospital-inpatient service should not be seen as a panacea for meeting all the needs of CMC and their families. It is critical to understand how the service integrates with the wider health and care system.

"Who Has the Relationship?": Caring for a Shared Population of Children with Medical Complexity

Background: Many academic pediatric centers care for children with medical complexity (CMC) through established complex care and palliative care programs. There are little prior data investigating best practices for collaboration between these two subspecialties in caring for CMC. Objectives: The aim of this study is to explore the distinct and overlapping roles and responsibilities of pediatric complex care and palliative care teams as identified by providers when caring for a shared population of CMC and their families. Design: Qualitative analysis of semi-structured interviews. Settings/Subjects: Pediatric complex care and palliative care providers (physicians and nurse practitioners) actively caring for CMC at academic medical centers in the Midwestern United States. Measurements: Data obtained from semi-structured interviews were audio-recorded, transcribed, coded, and analyzed by two independent reviewers using thematic analysis. Results: Interviews revealed that both programs operate within a spectrum of clinical roles, thematically organized as complex-leaning, palliative-leaning, or blended. Responses highlighted that clinical roles are more likely defined by relationships established between specific providers and families, instead of by clear boundaries between the two programs. Conclusions: Pediatric complex care and palliative care teams provide both distinct and overlapping roles in caring for CMC. This overlap can vary between institutions and individual provider-caregiver dyads. Further studies are needed to explore collaborative practices on shared patients and caregiver perceptions on the benefits and challenges of utilizing both teams concurrently. Key Message: This qualitative study of providers of CMC highlights the overlapping roles and responsibilities between complex care and palliative care teams in caring for a shared population of patients and families.

Children with medical complexity in the emergency department: Parent experiences and information needs

BACKGROUND

Children with complex medical needs constitute a growing number of pediatric patients that utilize the emergency department, disproportionately more than children outside of this category. Our objective for this qualitative study was to explore information needs and experiences of parents accessing emergency health care for their child with medical complexity.

METHODS

Qualitative description guided this study. Parent participants were recruited via purposive sampling and individually interviewed within a pediatric specialty clinic at a Canadian pediatric tertiary care center. Inductive content analysis organized interview data from parents.

RESULTS

Nine, 60-90 min individual interviews were conducted with parents of a child with medical complexity; four content categories emerged: How the emergency department is different for children with medical complexity, parents as key care coordinators, emergency department experience and resilience, and communication and learning preferences.

CONCLUSION

These families openly shared their experience with pediatric emergency care. Strategies to support transfer of pertinent health information for children with complex medical needs are needed in the emergency department. Interviews with parents of children with complex medical needs provided key insights to inform and improve the care provided in the emergency department for this growing population of children.

"Fitting the Pieces Together": The Experiences of Caregivers of Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Families of children with medical complexity manage a multitude of care responsibilities that must be carefully coordinated alongside typical family roles and activities. Currently, little is known about this experience from the perspectives of caregivers; therefore, the purpose of this study was to explore the experience of caregiving for a child with medical complexity while identifying unmet medical and psychosocial needs.

METHODS

Nineteen caregivers were recruited from the pediatric complex care clinic at an academic medical center in the United States. Each participant completed an in-depth, narrative interview that was audio-recorded and transcribed; transcripts were analyzed using an inductive coding approach.

RESULTS

Participants described their caregiving experiences along 4 themes: (1) the many responsibilities of caregiving, (2) insufficient respite care and skilled support, (3) financial limitations and costs of care, and (4) challenges with mental health and wellbeing. Participants identified unmet needs in 6 dimensions: (1) transition stress, (2) communication across teams, (3) learning to be an advocate, (4) purposefully inclusive environments, (5) finding connections and community, and (6) the challenges of coronavirus disease 2019.

CONCLUSIONS

Caregivers of children with medical complexity identify a host of experiences and unmet needs that challenge the physical, emotional, and psychosocial wellbeing of themselves and their families. With more attention to the holistic experience of caregiving for this population, providers and teams can better anticipate needs and provide services and programs that enhance caregiver and family wellbeing simultaneously.

Demographic and Clinical Differences Between Applied Definitions of Medical Complexity

OBJECTIVES

To identify the degree of concordance and characterize demographic and clinical differences between commonly used definitions of multisystem medical complexity in children hospitalized in children's hospitals.

METHODS

We conducted a retrospective, cross-sectional cohort study of children <21 years of age hospitalized at 47 US Pediatric Health Information System-participating children's hospitals between January 2017 to December 2019. We classified patients as having multisystem complexity when using 3 definitions of medical complexity (pediatric complex chronic conditions, pediatric medical complexity algorithm, and pediatric chronic critical illness) and assessed their overlap. We compared demographic, clinical, outcome, cost characteristics, and longitudinal healthcare utilization for each grouping.

RESULTS

Nearly one-fourth (23.5%) of children hospitalized at Pediatric Health Information System-participating institutions were identified as meeting at least 1 definition of multisystem complexity. Children with multisystem complexity ranged from 1.0% to 22.1% of hospitalized children, depending on the definition, with 31.2% to 95.9% requiring an ICU stay during their index admission. Differences were seen in demographic, clinical, and resource utilization patterns across the definitions. Definitions of multisystem complexity demonstrated poor agreement (Fleiss' κ 0.21), with 3.5% of identified children meeting all 3.

CONCLUSIONS

Three definitions of multisystem complexity identified varied populations of children with complex medical needs, with poor overall agreement. Careful consideration is required when applying definitions of medical complexity in health services research, and their lack of concordance should result in caution in the interpretation of research using differing definitions of medical complexity.