Continuity of care for children with complex chronic health conditions: parents' perspectives

Parents recounting their journey with stuttering: A preliminary exploration of experiences and adaptation

BACKGROUND/PURPOSE

Parents' attitudes and emotions toward stuttering have the potential to impact their reactions to their child's speech. Many parents lack sufficient knowledge about stuttering, which often leads to guilt, uncertainty, and helplessness when their child begins to stutter. However, these experiences may evolve later. This study aimed to explore parents' experiences, as well as their reflections on how these experiences have changed since the onset.

METHOD

Semi-structured interviews were conducted with 5 parents of individuals who stutter, and 9 other parents chose to complete an anonymous online survey with similar questions. Content analysis was used to identify patterns in parents' experiences, and thematic analysis was used to delineate the components of their change and adaptation process.

RESULTS

Four main themes emerged: 1) dynamic emotions of parents, reflecting the fluctuating feelings parents experienced; 2) social compromises, where parents made sacrifices because of their child's stuttering; 3) proactive and protective parenting, involving efforts to support and protect their child; and 4) beyond stuttering, emphasizing the recognition of the child's strengths. Furthermore, a preliminary framework was developed to describe parents' process of adaptation, encompassing six components: emotional struggles, concern and uncertainty, transition to action, seeking support and education, preparation and empowerment, and acceptance. These components were experienced in a non-linear fashion.

CONCLUSION

This study enhances our understanding of the socio-emotional journey that parents undergo in relation to their child's stuttering. The findings highlight the need for interventions that support both the child and the family and address the challenges parents face.

The renewed Development Model for Integrated Care: a systematic review and model update

BACKGROUND

Organising integrated health services beyond domains in interorganizational networks, can be supported by conceptual models to overview the complexity. The Development Model for Integrated Care (DMIC) is a systematically developed generic model that has been applied to innovate and implement integrated care services in a large range of (international) healthcare settings. After a decade, it is important to incorporate new available literature in the model. Therefore, our aim was to update and further develop the DMIC by incorporating the current body of knowledge.

METHODS

A systematic literature review and subsequent stepwise systematic update of the DMIC.

RESULTS

The review of the literature resulted in 179 included studies and eventually 20 new elements for the development model, which could be positioned in the nine clusters. New elements address the importance of the social system and community of the client, proactive care during the life span, digital (care) services and ethical and value driven collaboration in interorganizational networks that cross domains. The added elements for integrated care build further on the nine thematic clusters and the model as a whole, expanded with new accents.

CONCLUSION

The renewed model emphasizes the connectedness of care within a larger eco-system approach and inter-organizational networks. The model captures current knowledge which can be supportive as a generic conceptual model to develop, implement or innovate integrated services towards health value in societies. Further, it can serve for healthcare services research purposes to reflect on an monitor developments in integrated care settings over time on multiple levels.

Multidisciplinary coordination of care for children with esophageal atresia and tracheoesophageal fistula

Esophageal Atresia/Tracheoesophageal Atresia (EA/TEF) is a multisystem congenital anomaly. Historically, children with EA/TEF lack coordinated care. A multidisciplinary clinic was established in 2005 to provide coordinated care and improve access to outpatient care. This single-center retrospective cohort study was conducted to describe our cohort of patients with EA/TEF born between March 2005 and March 2011, assess coordination of care, and to compare outcomes of children in the multidisciplinary clinic to the previous cohort without a multi-disciplinary clinic. A chart review identified demographics, hospitalizations, emergency visits, clinic visits, and coordination of outpatient care. Twenty-seven patients were included; 75.9% had a C-type EA/TEF. Clinics provided multidisciplinary care and compliance with the visit schedule was high with a median of 100% (IQR 50). Compared to the earlier cohort, the new cohort (N = 27) had fewer hospital admissions and LOS was reduced significantly in the first 2 years of life. Multidisciplinary care clinics for medically complex children can improve coordination of visits with multiple health care providers and may contribute to reduced use of acute care services.

Investigating the Best Practices for Engagement in Remote Participatory Design: Mixed Methods Analysis of 4 Remote Studies With Family Caregivers

BACKGROUND

Digital health interventions are a promising method for delivering timely support to underresourced family caregivers. The uptake of digital health interventions among caregivers may be improved by engaging caregivers in participatory design (PD). In recent years, there has been a shift toward conducting PD remotely, which may enable participation by previously hard-to-reach groups. However, little is known regarding how best to facilitate engagement in remote PD among family caregivers.

OBJECTIVE

This study aims to (1) understand the context, quality, and outcomes of family caregivers' engagement experiences in remote PD and (2) learn which aspects of the observed PD approach facilitated engagement or need to be improved.

METHODS

We analyzed qualitative and quantitative data from evaluation and reflection surveys and interviews completed by research and community partners (family caregivers) across 4 remote PD studies. Studies focused on building digital health interventions for family caregivers. For each study, community partners met with research partners for 4 to 5 design sessions across 6 months. After each session, partners completed an evaluation survey. In 1 of the 4 studies, research and community partners completed a reflection survey and interview. Descriptive statistics were used to summarize quantitative evaluation and reflection survey data, while reflexive thematic analysis was used to understand qualitative data.

RESULTS

In 62.9% (83/132) of evaluations across projects 1-3, participants described the session as "very effective." In 74% (28/38) of evaluations for project 4, participants described feeling "extremely satisfied" with the session. Qualitative data relating to the engagement context identified that the identities of partners, the technological context of remote PD, and partners' understanding of the project and their role all influenced engagement. Within the domain of engagement quality, relationship-building and co-learning; satisfaction with prework, design activities, time allotted, and the final prototype; and inclusivity and the distribution of influence contributed to partners' experience of engagement. Outcomes of engagement included partners feeling an ongoing interest in the project after its conclusion, gratitude for participation, and a sense of meaning and self-esteem.

CONCLUSIONS

These results indicate high satisfaction with remote PD processes and few losses specific to remote PD. The results also demonstrate specific ways in which processes can be changed to improve partner engagement and outcomes. Community partners should be involved from study inception in defining the problem to be solved, the approach used, and their roles within the project. Throughout the design process, online tools may be used to check partners' satisfaction with design processes and perceptions of inclusivity and power-sharing. Emphasis should be placed on increasing the psychosocial benefits of engagement (eg, sense of community and purpose) and increasing opportunities to participate in disseminating findings and in future studies.

Drivers that decrease hospital-delivered care in children with medical complexity: Parental perspectives

Background and objective

Children with medical complexity (CMC) have chronic and severe conditions leading to medical fragility. CMC represent less than 1% of children but account for one-third of paediatric healthcare expenditures. Enrollment to a complex care program (CCP) decreases health care resource utilization while improving parental satisfaction. An in-depth understanding of how these changes operate in real-world setting is needed to further support CMC and their families. This study aimed at assessing the possible reasons for a decrease in emergency department (ED) visits and hospitalization length of stay related to enrollment to a CCP, based on parental perspectives.

Study design

Using a qualitative approach, data were collected using in-depth, semi-structured interviews with parents of CMC enrolled in a CCP from a university hospital centre in Montreal, Canada. The interview guide was co-constructed by an interdisciplinary team, including a parent partner and a clinical nurse coordinator. Themes have been identified inductively, using thematic analysis.

Results

Parents identified personalized care, family empowerment and guidance as enablers arising from the CCP that contributed to the decrease in hospital-delivered care utilization. Improvement in medical baseline condition was also identified as a contributing factor, while not necessarily related to program's support.

Conclusions

In this study, we identified personalized care, parental empowerment, and guidance as three strategies for a CCP to potentially decrease ED visits and hospital length of stay, from the parents' perspective. Parents identified the clinical nurse coordinator as playing a central role in supporting the implementation of these strategies.

Go Team Go! Interprofessional Practice for Pediatric Feeding in the Schools

PURPOSE

The purpose of this clinical focus article is to discuss processes and procedures for building school-based programs to address the feeding and swallowing needs of students in the public-school setting. Interprofessional practice (IPP) team member roles and responsibilities, screening, eligibility, considerations for developing Individualized Education Programs that address the needs of students with pediatric feeding disorder (PFD) and dysphagia, as well as billing documentation requirements, are discussed. Additionally, coordination across the continuum of service delivery for students with PFD and dysphagia is investigated. Guidance on documentation, processes, and procedures that comply with the Individuals with Disabilities Education Act mandates will be provided.

CONCLUSIONS

This clinical focus article will demonstrate that students with PFD and dysphagia continue to present to public schools and require skilled services and supports in order to meet their individualized needs. School-based speech-language pathologists have a legal requirement to provide these supports when deemed educationally relevant. Schools must employ processes and procedures that result in the timely and effective evaluation and identification of students with PFD and dysphagia. An IPP approach to the management of PFD and dysphagia is critical to ensure optimal outcomes for students found eligible for services.

[Screening for Duchenne muscular dystrophy in newborns in the Ningxia region]

OBJECTIVES

To evaluate the incidence rate of Duchenne muscular dystrophy (DMD) in the male newborns in the Ningxia region and establish a critical threshold for screening DMD in newborns to distinguish between the normal population and affected individuals.

METHODS

A total of 10 000 male newborns were screened using immunofluorescence analysis of creatine kinase isoenzyme concentrations in heel spot dried blood specimens. Newborns with the concentrations higher than the critical threshold were recalled for serum creatine kinase measurements. Genetic testing was performed to confirm diagnosis in cases showing abnormalities.

RESULTS

Among the screened 10 000 male newborns, two were confirmed to have DMD through genetic testing, resulting in a preliminary estimated incidence rate of 1/5 000 for male newborns in the Ningxia region. The critical threshold for creatine kinase isoenzyme concentration in newborns in this region was determined to be 468.57 ng/mL.

CONCLUSIONS

Screening for DMD in newborns is feasible in the Ningxia region. Early screening, diagnosis, and treatment of DMD can improve the quality of life for affected individuals and help families make informed decisions regarding further pregnancies.

Coping Factors for Caregivers of Children With Medical Complexity During Hospitalization

OBJECTIVES

This study aimed to identify coping factors for caregivers of children with medical complexity (CMC) to manage the stressors and experience associated with their child's hospitalization.

METHODS

We conducted semistructured interviews with CMC caregivers over a video-conferencing platform to examine factors that they perceive impact their coping while their children are hospitalized. Interviews were audio-recorded, transcribed, and imported into a qualitative coding software (MAXQDA). Using a modified grounded theory approach, we assigned process and in vivo codes to the transcripts and conducted interpretive analysis to identify themes. Once we reached thematic saturation, we finalized themes by discussing them to achieve group consensus and processed themes through triangulation with our institution's pediatric family advisory council.

RESULTS

We interviewed 14 caregivers (11 mothers and 3 fathers) and identified 3 major themes. The factors that contributed to CMC caregiver coping with their child's hospitalizations included caregivers: feeling that they are prioritizing their child's needs over their own, feeling trust in their child's interdisciplinary healthcare team, and feeling their self-care practices are well adjusted to the hospital setting.

CONCLUSIONS

Our study found 3 coping factors for caregivers of CMC during their child's hospitalization. Development and testing of interventions that enhance these coping practices may better support CMC caregivers during their child's hospitalizations. Potential interventions could include developing structured processes to establish caregiver involvement in their child's hospital care and helping caregivers modify their existing coping mechanisms to the hospital setting.

Toward Comprehensive Care Integration in Canada: Delphi Process Findings from Researchers, Clinicians, Patients and Decision Makers

Introduction

From a larger study examining policy and program information on how Canadian provinces integrate care services, this study aimed to create "priority lists" of 10-15 services that are "absolutely needed" for care integration.

Methodology

A diverse group of over 50 Canadian stakeholders participated in virtual consensus-building using the nominal group technique and a modified e-Delphi method to identify services that focused on two different groups: children and youth with high functional health needs and older adults in functional decline.

Results

Three lists - containing services, processes and infrastructure elements - emerged: one per tracer condition group and a consolidated list. The latter identified the following five services as top priority for primary care integration: mental health and addictions services; home care; transition between urgent-emergency-acute care; medication reconciliation in community pharmacies; and respite care. No single social service was a clear priority, but those that mitigate material deprivation emerged within the top 10.

Discussion

This humble pan-Canadian study shows that priority services in health and social services are neither well integrated nor connected to primary care. It also suggests that effective policy strategizing for primary care integration for those with complex care needs may require thinking beyond the logic of services - given their siloed organization.

Connecting Health and Social Services for Patients with Complex Care Needs: A Pan-Canadian Comparative Policy Research Program

Comprehensive primary healthcare for patients with complex care needs requires connections to other health services, social services and community supports. This descriptive comparative policy research program used publicly available documents and informant interviews to examine progress toward integrated comprehensive care through the lens of services needed by children and youth (0-25 years) and community-dwelling older adults (≥ 65 years) with high functional health needs. This article describes five projects. The following three findings emerged across all the projects: Canada indeed has multiple health systems; numerous integrated service delivery solutions are being trialled and most focus on medical services; and it is an ongoing challenge for ministries of health to engage physicians and physician associations in integration.

Effectiveness of Structured Care Coordination for Children With Medical Complexity: The Complex Care for Kids Ontario (CCKO) Randomized Clinical Trial

Importance

Children with medical complexity (CMC) have chronic conditions and high health needs and may experience fragmented care.

Objective

To compare the effectiveness of a structured complex care program, Complex Care for Kids Ontario (CCKO), with usual care.

Design, Setting, and Participants

This randomized clinical trial used a waitlist variation for randomizing patients from 12 complex care clinics in Ontario, Canada, over 2 years. The study was conducted from December 2016 to June 2021. Participants were identified based on complex care clinic referral and randomly allocated into an intervention group, seen at the next available clinic appointment, or a control group that was placed on a waitlist to receive the intervention after 12 months.

Intervention

Assignment of a nurse practitioner-pediatrician dyad partnering with families in a structured complex care clinic to provide intensive care coordination and comprehensive plans of care.

Main Outcomes and Measures

Co-primary outcomes, assessed at baseline and at 6, 12, and 24 months postrandomization, were service delivery indicators from the Family Experiences With Coordination of Care that scored (1) coordination of care among health care professionals, (2) coordination of care between health care professionals and families, and (3) utility of care planning tools. Secondary outcomes included child and parent health outcomes and child health care system utilization and cost.

Results

Of 144 participants randomized, 141 had complete health administrative data, and 139 had complete baseline surveys. The median (IQR) age of the participants was 29 months (9-102); 83 (60%) were male. At 12 months, scores for utility of care planning tools improved in the intervention group compared with the waitlist group (adjusted odds ratio, 9.3; 95% CI, 3.9-21.9; P < .001), with no difference between groups for the other 2 co-primary outcomes. There were no group differences for secondary outcomes of child outcomes, parent outcomes, and health care system utilization and cost. At 24 months, when both groups were receiving the intervention, no primary outcome differences were observed. Total health care costs in the second year were lower for the intervention group (median, CAD$17 891; IQR, 6098-61 346; vs CAD$37 524; IQR, 9338-119 547 [US $13 415; IQR, 4572-45 998; vs US $28 136; IQR, 7002-89 637]; P = .01).

Conclusions and Relevance

The CCKO program improved the perceived utility of care planning tools but not other outcomes at 1 year. Extended evaluation periods may be helpful in assessing pediatric complex care interventions.

Trial Registration

ClinicalTrials.gov Identifier: NCT02928757.

Providing care for children with tracheostomies: a qualitative interview study with parents and health professionals

OBJECTIVES

To explore the experience of caring for children with tracheostomies from the perspectives of parents and health professional caregivers.

DESIGN

Qualitative semistructured interview study.

SETTING

One region in England covered by a tertiary care centre that includes urban and remote rural areas and has a high level of deprivation.

PARTICIPANTS

A purposive sample of health professionals and parents who care for children who have, or have had, tracheostomies and who received care at the tertiary care centre.

INTERVENTION

Interviews undertaken by telephone or video link.

PRIMARY AND SECONDARY OUTCOME MEASURES

Qualitative reflexive thematic analysis with QSR Nvivo 12.

RESULTS

This paper outlines key determinants and mediators of the experiences of caregiving and the impact on psychological and physical health and quality of life of parents and their families, confidence of healthcare providers and perceived quality of care. For parents, access to care packages and respite care at home as well as communication and relationships with healthcare providers are key mediators of their experience of caregiving, whereas for health professionals, an essential influence is multidisciplinary team working and support. We also highlight a range of challenges focused on the shared care space, including: a lack of standardisation in access to different support teams, care packages and respite care, irregular training and updates, and differences in health provider expertise and experiences across departments and shift patterns, exacerbated in some settings by limited contact with children with tracheostomies.

CONCLUSIONS

Understanding the experiences of caregiving can help inform measures to support caregivers and improve quality standards. Our findings suggest there is a need to facilitate further standardisation of care and support available for parent caregivers and that this may be transferable to other regions. Potential solutions to be explored could include the development of a paediatric tracheostomy service specification, increasing use of paediatric tracheostomy specialist nurse roles, and addressing the emotional and psychological support needs of caregivers.

Parent-to-parent peer support for children and youth with special health care needs: Preliminary evaluation of a family partner program in a healthcare system

PURPOSE

Children and youth with special health care needs (CYSHCN) have complex care and coordination needs that are often managed by parents or primary caregivers. This study describes a parent-to-parent peer support pilot program for parents of CYSHCN implemented in both outpatient and inpatient settings across a large health system.

DESIGN & METHODS

Retrospective data from the Family Partner Program documentation in patient health records are described. Descriptions about the encounters and types of support provided are also reviewed using qualitative descriptive analysis.

RESULTS

Three Family Partners conducted 203 encounters with parents of 90 CYSHCN over six months. Family Partners provided both emotional and tangible support. Primary themes discussed included the persistent care, coordination and management needs related to parenting a child with complex care needs, the subsequent worry and stress about their child and family, and the need for stress management and self-care.

CONCLUSION

This study provides early evidence that implementation of a parent-to-parent peer support program for parents of CYSHCN in a large, academic medical center is feasible. Family Partners enhanced their healthcare team's ability to provide patient- and family-centered support for pediatric patients and their families through the provision of emotional and tangible support.

PRACTICE IMPLICATIONS

Family Partners, who are trained in effective use of the shared experience, the health coach model, and healthcare systems, and who are supported by a strong supervisory team, are ideally suited to support families and patients as they address their concerns and unmet needs and navigate complex health circumstances.

Destination unknown: Parents and healthcare professionals' perspectives on transition from paediatric to adult care in Down syndrome

BACKGROUND

Transitioning from paediatric medical care to adult care is a challenging process for children, parents and healthcare professionals. The aim of this study was to explore the experiences, concerns and needs of parents of children with Down syndrome and of professionals regarding this transition.

METHOD

A qualitative study was performed using semi-structured interviews with 20 parents of children with Down syndrome and six healthcare professionals.

RESULTS

We showed that parents and professionals have concerns during each of the three distinct phases of transition (preparation, transfer and integration). Data disclose specific concerns regarding communication, continuity of care and rebuilding trust. We propose a framework for the transition to adult care.

CONCLUSIONS

The transition in medical care for children with Down syndrome should be flexible, patient-centred and coordinated together with patients and parents. Only in ensuring continuity of care will individuals with Down syndrome not get lost in transition.

Perceptions and experiences of care providers as clients of NaviCare/SoinsNavi: a patient navigation centre for children and youth with complex care needs

Objective

NaviCare/SoinsNavi is a bilingual patient navigation centre for children and youth 25 years of age or younger with complex care needs in New Brunswick. This research-based centre employs two bilingual patient navigators, one a registered nurse and the other a lay navigator, who assist children/youth, family members and the care team by facilitating more convenient and integrated care using a personalised family-centred approach. The purpose of this study was to explore the perceptions and experiences of care providers who use NaviCare/SoinsNavi. This study builds on ongoing research exploring the experiences of children/youth and their families who are clients of NaviCare/SoinsNavi.

Methods

Interviews were conducted with 10 care providers (n=10) from various sectors including social support services (n=6), primary care (n=2), mental health services (n=1) and acute care (n=1).

Results

Qualitative interviews were conducted and five themes related to the participants’ perceptions and experiences with NaviCare/SoinsNavi emerged, including : (1) trusted source, (2) connector, (3) capacity builder, (4) partner and (5) time saver. The overall impression of NaviCare/SoinsNavi was positive in the service’s ability to help support care providers and streamline the care they provide to their clients.

Conclusions

It is within every healthcare provider’s scope of practice to provide navigational support to essential programmes and services; however, due to limitations in time, resources and capacity, services such as NaviCare/SoinsNavi can be used to help close gaps in care that exists for children/youth with complex care needs and their families.

Implementing a Care Coordination Strategy for Children with Medical Complexity in Ontario, Canada: A Process Evaluation

Introduction:

A provincial strategy to expand care coordination and integration of care for children with medical complexity (CMC) was launched in Ontario, Canada in 2015. A process evaluation of the roll-out examined the processes, mechanisms of impact, and contextual factors affecting the implementation of the Complex Care for Kids Ontario (CCKO) intervention strategy.

Methods:

This process evaluation was conducted and analyzed according to the United Kingdom Medical Research Council (UK-MRC) process evaluation framework. To evaluate the implementation of the CCKO intervention, a multi-method study design was used, including semi-structured interviews with 38 key informants and 10 families of CMC involved in CCKO. To further understand implementation details across regional sites, provincial-level implementation plans, and process documents were reviewed.

Discussion:

Strengths of CCKO included novel collaborations and partnerships between complex care teams, community partners and regional sites. Issues relating to communication and coordination across care sectors created challenges to holistic care coordination objectives. Provincial system fragmentation limited the ability of CCKO to provide seamless care coordination due to the multiple care sectors involved.

Conclusion:

This study adds to the understanding of the processes involved in a population-level care coordination intervention for CMC. Lessons learned through CCKO can help facilitate reproducibility and necessary adjustments of the intervention in different settings.

Hospital-based patient navigation programmes for patients who experience injury-related trauma and their caregivers: a scoping review protocol

INTRODUCTION

Patients who experience injury-related trauma tend to have complex care needs and often require support from many different care providers. Many patients experience gaps in care while in the hospital and during transitions in care. Providing access to integrated care can improve outcomes for these patients. Patient navigation is one approach to improving the integration of care and proactively supporting patients and their caregivers as they navigate the healthcare system. The objective of this scoping review is to map the literature on the characteristics and impact of hospital-based patient navigation programmes that support patients who experience injury-related trauma and their caregivers.

METHODS AND ANALYSIS

This review will be conducted in accordance with Joanna Briggs Institute methodology for scoping reviews. The review will include primary research studies, unpublished studies and evaluation reports related to patient navigation programmes for injury-related trauma in hospital settings. The databases to be searched will include CINAHL (EBSCO), EMBASE (Elsevier), ProQuest Nursing & Allied Health, PsycINFO (EBSCO) and MEDLINE (Ovid). Two independent reviewers will screen articles for relevance against the inclusion criteria. Results will be presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses for Scoping Reviews (PRISMA-ScR) flow diagram and follow the PRISMA-ScR checklist. The extracted data will be presented both tabularly and narratively.

ETHICS AND DISSEMINATION

Ethics approval is not required, as the scoping review will synthesise information from publicly available material. To disseminate the findings of this review, the authors will submit the results for publication in a medical or health sciences journal, present at relevant conferences and use other knowledge translation strategies to reach diverse stakeholders (eg, host webinars, share infographics).

It's more than just lubrication of the skin: parents' experiences of caring for a child with ichthyosis

Background: The ichthyoses are a group of genetic skin disorders, characterized by excessive amounts of dry, thickened skin, which may be fragile, inelastic and prone to fissures and infection. Skin care is time consuming and demanding, and, usually performed by the parents.

Methods: We aimed to explore parental experience of caring for a child with ichthyosis, and collected data using semistructured interview, and thematic analysis.

Results: Our analysis revealed four main themes: Parents' and others' reactions to the child's difference, Experiences with healthcare services, It's all skin care, and Impact on relationships.

Conclusion: After birth of a child with severe ichthyosis, the parents experienced emotional distress and stigmatization due to the different appearance of the skin and healthcare professionals' lack of knowledge. Skin care caused pain in the child, was time consuming, and caused financial burdens. This study can guide healthcare professionals on where to focus future efforts in meeting the clinical and psychological needs of parents caring for a child with ichthyosis.

A pilot study of disease related education and psychotherapeutic support for unresolved grief in parents of children with CF

Diagnosis of chronic disease in a child can result in unresolved grief (UG) in parents. This study aimed to evaluate the efficacy of psychological insight-oriented therapy (IOT) as a treatment for UG compared to disease related education in parents of children with cystic fibrosis (CF). Sequence of delivery, first IOT then disease related education (or vice versa) was also examined, to let all participants experience both interventions. Parents were screened for UG. Parents with UG were randomised to either five 1-h sessions of IOT or five 1-h sessions of education. Measures were assessed pre-intervention, after the first intervention period (primary efficacy assessment), and after the second intervention period (swapping intervention). Forty-seven parents were screened of which 46.8% (22/47) had UG. Median duration of UG was 5 years (range: 6 months–14 years). Anxiety (50% vs. 20%, p = 0.03) and stress (59% vs. 28%, p = 0.03) were significantly more prevalent in parents with UG. There was no difference between arms in the odds of UG resolving either following the first intervention period (OR 0.88; 95% CI 0.5, 1.5) or the second intervention period (OR 0.91; 95% CI 0.5, 1.6). While not statistically significant, adjusted mean values for seven of the eight mental health measures were lower in the IOT (first) arm compared to the ED (first) arm, following the first intervention period. UG is a significant burden for families affected by CF. Provision of disease related education and psychological support, regardless of sequence, can result in resolution of grief.

Trial registration number: ACTRN12621000796886, date of registration 24/06/2021, retrospectively registered.

Families' healthcare experiences for children with inherited metabolic diseases: protocol for a mixed methods cohort study

INTRODUCTION

Children with inherited metabolic diseases (IMDs) often have complex and intensive healthcare needs and their families face challenges in receiving high-quality, family centred health services. Improvement in care requires complex interventions involving multiple components and stakeholders, customised to specific care contexts. This study aims to comprehensively understand the healthcare experiences of children with IMDs and their families across Canada.

METHODS AND ANALYSIS

A two-stage explanatory sequential mixed methods design will be used. Stage 1: quantitative data on healthcare networks and encounter experiences will be collected from 100 parent/guardians through a care map, 2 baseline questionnaires and 17 weekly diaries over 5-7 months. Care networks will be analysed using social network analysis. Relationships between demographic or clinical variables and ratings of healthcare experiences across a range of family centred care dimensions will be analysed using generalised linear regression. Other quantitative data related to family experiences and healthcare experiences will be summarised descriptively. Ongoing analysis of quantitative data and purposive, maximum variation sampling will inform sample selection for stage 2: a subset of stage 1 participants will participate in one-on-one videoconference interviews to elaborate on the quantitative data regarding care networks and healthcare experiences. Interview data will be analysed thematically. Qualitative and quantitative data will be merged during analysis to arrive at an enhanced understanding of care experiences. Quantitative and qualitative data will be combined and presented narratively using a weaving approach (jointly on a theme-by-theme basis) and visually in a side-by-side joint display.

ETHICS AND DISSEMINATION

The study protocol and procedures were approved by the Children's Hospital of Eastern Ontario's Research Ethics Board, the University of Ottawa Research Ethics Board and the research ethics boards of each participating study centre. Findings will be published in peer-reviewed journals and presented at scientific conferences.

Caregiver's Perspectives on the Healthcare Experiences of Children With Behaviour-Related Disorders

Objective: Social Pediatrics focuses on targeting and mitigating the effects of the social determinants of health on a child’s well-being and development. Negative health outcomes have been seen in children who have faced poverty, food insecurity, inadequate housing, and traumatic events. In particular, children who come from socioeconomically disadvantaged households are more likely to develop behavioural problems. The purpose of this study is to explore the experiences of caregivers for children with a behaviour-related disorder. This includes children affected by attention, academic, and social issues (e.g. attention-deficit hyperactivity disorder, autism spectrum disorder). This study will aim to understand the strengths, barriers, and social limitations to accessing and receiving care for children with behavioural disorders. 

Methods: A qualitative descriptive design was used to conduct three focus groups. Of the 64 caregivers contacted, a total of 13 participants agreed to be in the study. All focus groups were analyzed using inductive thematic analysis. 

Results: Preliminary findings suggest that caregivers value pediatricians who spend time, communicate, and make a human connection with their patients. Barriers included physician turnover, long wait times for referrals, and a lack of knowledge regarding services and programs available in their area. Three major themes emerged from this study including (1) timeliness to care, (2) advocacy, and (3) relationship building.

Conclusion: Findings suggested that caregivers valued pediatricians who spend time to make a human connection with their patients. Barriers included physician turnover, long wait times for referrals, and a lack of knowledge of available services. Caregivers who were young mothers felt an added layer of judgement when accessing the necessary care for their children. This study is important as it contributes to our knowledge on the role Social Pediatrics can play in the care of children with behaviour-related disorders. 

Young children's experiences of support when fearful during treatment for acute lymphoblastic leukaemia-A longitudinal interview study

AIM AND OBJECTIVES

To describe young children's experiences of valuable support in managing their fears about treatment for acute lymphoblastic leukaemia. The focus was specifically on support from parents and healthcare professionals.

DESIGN

The study had a qualitative descriptive longitudinal design.

METHODS

The study analysed 35 interviews with 13 children at three different times during their treatment period. Data were analysed using a matrix-based method. The Consolidated criteria for reporting qualitative research (COREQ) guidelines have been followed.

RESULTS

Parents and healthcare professionals provide important support to children undergoing treatment for acute lymphoblastic leukaemia, although their roles differ. Children valued their parents' closeness and advocacy, being able to participate in their own care, and being given pain relief during procedures known to create pain. Valued support from healthcare professionals changed over time, from providing information and showing the tools that would be used in procedures, to paying attention to the child's needs and desires. It was more important for children to be able to choose between different alternatives in medical procedures than deciding on major treatment issues.

Parents' report on the health care management of spina bifida in early childhood

PURPOSE

This study aimed to describe health care use by type of health providers and care settings visited by children with spina bifida (SB) and to compare this use between children with and without a shunt.

METHODS

Health care use data were extracted from a larger study on the health and functioning of children with SB aged 3-6 years. The present study focused on the medical information subsection of a parent-reported survey related to SB care, general care, specialty care (e.g., neurosurgery), emergency care, and complications related to SB and shunts.

RESULTS

Parents of 101 children with SB participated. Most of the children were male with myelomeningocele and had a shunt. They visited a health care provider for SB care an average of 7.4 times and a specialist an average of 11.9 times in the previous 12 months. Most visited a multidisciplinary clinic for SB-related care and a private physician's office for general care. Children with a shunt had more SB-related medical visits, more visits to a specialist, and a greater number of different types of specialists than those without it. Frequency of emergency room visits did not differ between the two groups. Health providers informed parents about headaches, vomiting, and fever as signs of complications, and some parents did report shunt-related complications.

CONCLUSION

SB is a complex medical condition requiring that children receive medical care from various medical specialists, especially for children with a shunt. Findings on health care use suggest high levels of monitoring and care coordination that parents navigate to care for their child.

Perceptions of the caregiver-pediatric physical therapist relationship1

PURPOSE

Collaboration between physical therapists and caregivers of children who receive physical therapy is integral to providing family-centered care. Successful collaboration depends upon the therapeutic relationship built within the caregiver-therapist dyad. However, the nature of these relationships is not well understood. The purpose of this study was to explore the caregiver-pediatric physical therapist relationship from the perspectives of the caregiver and pediatric physical therapist.

METHODS

A qualitative multiple case study methodology was used; a caregiver and pediatric physical therapist represented a bounded case. Each caregiver and therapist engaged in separate, semi-structured, in-depth interviews.

RESULTS

Through within- and cross-case coding, three themes were identified: physical therapist as a guide, the caregiver-pediatric physical therapist connection, and professional qualities and performance.

CONCLUSION

These themes help to provide an understanding of the therapeutic relationships that can occur between caregivers and pediatric physical therapists, which can help support effective collaboration as part of providing family-centered care.

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

OBJECTIVE

Pediatric complex care centers are an increasingly common approach to address the needs of children with medical complexity (CMC). We sought to better understand CMC caregivers' perceptions of what constitutes high-quality care at a complex care center.

METHODS

We conducted a cross-sectional qualitative study of family caregivers of CMC receiving care at a pediatric complex care center situated within a tertiary-care children's hospital. In-depth, semistructured interviews focused on caregivers' general experiences at the clinic, positive and negative experiences related to core components of the pediatric medical home, and recommendations for improvements. We thematically analyzed transcripts through a mixed inductive and deductive approach, using constant comparative methodology, with the pediatric medical home model as an organizing framework.

RESULTS

We conducted interviews with 20 participants (18 [90%] biological parents; 19 [95%] female; mean age 39 years) in outpatient settings. Caregivers described 2 major themes: 1) the value of having a clinician "quarterback" who is in-charge of their child's care and caregivers' go-to for questions and concerns, and 2) wanting clinicians who are personally invested in and willing to "go above and beyond" for their child. Participants discussed how and which components of the medical home model enable CMC clinicians to meet these needs.

CONCLUSIONS

Family caregivers of CMC want clinicians who take responsibility for managing their child's overall care and demonstrate personal commitment to ensuring their child's well-being. Multiple aspects of the medical home framework, rather than care coordination alone, help meet caregivers' perceptions of high-quality complex care.

Understanding the Implications of Peer Support for Families of Children With Neurodevelopmental and Intellectual Disabilities: A Scoping Review

Background: Families are integrally involved in day-to-day caregiving of children with neurodevelopmental and intellectual disabilities (NDID). Given the widespread and increasing prevalence of children with NDID and the impact of family caregiving on psychological, social, and economic implications for both the child and family, understanding and supporting these families is an important public health concern. Objective: We conducted a scoping review on peer support networks to understand their implications on families. Considering increasing prevalence of NDID's, understanding the implications of existing networks is critical to improve and nurture future support networks that can complement and reduce the burden on existing formal support systems. Design: A comprehensive search of multiple databases was conducted. Articles were screened by two reviewers and any disagreements were resolved by a third reviewer. We explored existing research on parent-to-parent peer support networks, which included networks that developed informally as well as those that involved a formal facilitator for the group interpersonal processes. There were no limits on the study design, date and setting of the articles. We included all research studies in English that included an identifier for (i) "peer support networks," (ii) "children with neurodevelopmental and intellectual disabilities" and (iii) "family caregiver outcomes." Results: We identified 36 articles. Majority of the studies were conducted in North America, and were face to face networks. They included families of children with a wide range of NDIDs. Relevant information extracted from different studies highlighted peer support network characteristics and development process, needs of family caregivers attending these networks, factors affecting caregiver participation and the impact of peer support networks on family caregivers. These networks represent a way to strengthen family caregivers, developing resilience and social interactions. Family caregivers sharing similar experiences support one another and provide critical information to each other. Although results are encouraging, future studies incorporating improved study designs are needed to better evaluate the effectiveness of peer support networks. Furthermore, studies where peer support networks develop organically while the child is supported are warranted. Conclusion: Although results obtained are encouraging, our findings support the need for further research studies of peer support networks with better designs and more detailed description of the factors involved in the development.

Care coordination guidelines for the care of people with spina bifida

Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a person's care to facilitate the appropriate delivery of health care services. Organizing care involves the marshalling of personnel and other resources needed to carry out all required patient care activities. It is often managed by the exchange of information among participants responsible for different aspects of care [1]. With an estimated 85% of individuals with Spina Bifida (SB) surviving to adulthood, SB specific care coordination guidelines are warranted. Care coordination (also described as case management services) is a process that links them to services and resources in a coordinated effort to maximize their potential by providing optimal health care. However, care can be complicated due to the medical complexities of the condition and the need for multidisciplinary care, as well as economic and sociocultural barriers. It is often a shared responsibility by the multidisciplinary Spina Bifida team [2]. For this reason, the Spina Bifida Care Coordinator has the primary responsibility for overseeing the overall treatment plan for the individual with Spina Bifida[3]. Care coordination includes communication with the primary care provider in a patient's medical home. This article discusses the Spina Bifida Care Coordination Guideline from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida and explores care coordination goals for different age groups as well as further research topics in SB care coordination.

Process Evaluation of a Hub-and-Spoke Model to Deliver Coordinated Care for Children with Medical Complexity across Ontario: Facilitators, Barriers and Lessons Learned

Background:

Complex Care for Kids Ontario (CCKO) is a multi-year strategy aimed at expanding a hub-and-spoke model to deliver coordinated care for children with medical complexity (CMC) across Ontario.

Objective:

This paper aims to identify the facilitators, barriers and lessons learned from the implementation of the Ontario CCKO strategy.

Method:

Alongside an outcome evaluation of the CCKO strategy, we conducted a process evaluation to understand the implementation context, process and mechanisms. Semi-structured interviews were conducted with 38 healthcare leaders, clinicians and support staff from four regions involved in CCKO care delivery and/or governance.

Results:

Facilitators to CCKO implementation were sustained engagement of system-wide stakeholders, inter-organizational partnerships, knowledge sharing and family engagement. Barriers to CCKO implementation were resources and funding, fragmentation of care, aligning perspectives between providers and clinical staff recruitment and retention.

Conclusion:

A flexible approach is required to implement a complex, multi-centre policy strategy. Other jurisdictions considering such a model of care delivery would benefit from attention to contextual variations in implementation setting, building cross-sector engagement and buy-in, and offering continuous support for modifications to the intervention as and when required.

A study of paediatric patients with complex chronic conditions admitted to a paediatric department over a 12 month period

INTRODUCTION

The number of patients with complex chronic conditions (CCC) has increased in the last 20 years or so. There is limited data as regards the prevalence of CCC in the paediatric population and its impact on hospital admissions. The main objectives of this study are to determine the proportion of CCC in the paediatric hospital population and compare them with other groups of patients admitted (acute and chronic).

PATIENTS AND METHODS

A descriptive, retrospective study was carried out in a tertiary maternity-paediatric hospital (from December 2016 to November 2017). All patients admitted into the Paediatric Department were recruited with a fortnightly frequency. A series of demographic, clinical, and pregnancy data were collected. In order to identify the level of complexity of the patients, the Clinical Risk Group (CRG) was used, with 3 groups being created: acute, chronic, and CCC. Statistics analysis was performed using SPSS v24.

RESULTS

A total of 1433 patients were included. The proportion of CCC on the Paediatric Ward was 14.4%. The CCC were older patients, mainly admitted due to decompensation or progression of their underlying disease, had a longer admission time, and required support in the Paediatric Intensive Care Unit (PICU) more often than that of the other sub-groups. Just under half (44.7%) of the CCC were carriers of a technological device. Of the total of long stays (>1 month), 71.3% had CCC.

CONCLUSIONS

Patients with CCC require long hospital stays, a greater need of intensive care, and use of technology. New approaches to treatment and follow-up need to be established. They should be cost-effective, and at the same time decrease the impact of the disease on the children and their family.

Continuity of Care in Chronic Diseases: A Concept Analysis by Literature Review

PURPOSE

This study aimed to utilize concept analysis to obtain a better understanding of the concept of "continuity of care" in chronic diseases.

METHODS

The concept of continuity of care was analyzed using the Walker and Avant method. Covering literature in English from 1930 to 2018, the data sources included CINAHL Complete, Academic Search Complete, MEDLINE, PsyARTICLES, Health Source: Nursing/Academic Edition, Google Scholar, Science Direct, and the Cochrane Library.

RESULTS

A comprehensive definition of concept of continuity of care was developed based on a systematic search and synthesis. The key defining attributes were identified as (a) care over time, (b) the relationship between an individual patient and a care team, (c) information transfer, (d) coordination, and (e) meeting changing needs. The antecedents of continuity of care were having a chronic disease, inexperienced with disease management, a poorly coordinated healthcare system, and medical care limitations. The consequences of continuity of care were decreasing hospital admissions, reducing costs, reducing emergency room visits, improving the quality of life, improving patient satisfaction, and delivering good healthcare.

CONCLUSION

The thorough concept analysis provides insight into the nature of "continuity of care" in chronic diseases and also helps ground the concept in healthcare.

Exploring the value of social network 'care maps' in the provision of long-term conditions care

OBJECTIVES

There is renewed attention to the role of social networks as part of person-centred long-term conditions care. We sought to explore the benefits of 'care maps' - a patient-identified social network map of their care community - for health professionals in providing person-centred care.

METHODS

We piloted care maps with 39 patients with long-term conditions in three urban and one rural general practice and two hospital wards. We interviewed the health professionals (n = 39) of these patients about what value, if any, care maps added to patient care. We analysed health professional interview data using thematic analysis to identify common themes.

RESULTS

Health professionals all said they learned about their patients as a person-in-context. There was an increased understanding of patients' support networks, synthesising what is known and unknown. Health professionals understood patients' perceptions of health professionals and what really mattered to patients. There was discussion about the therapeutic value of care maps. The maps prompted reflection on practice.

DISCUSSION

Care maps facilitated a broader focus than the clinical presentation. Using care maps may enable health professionals to support self-management rather than feeling responsible for many aspects of care. Care maps had 'social function' for health professionals. They may be a valuable tool for patients and clinicians to bridge the gap between medical treatment and patients' lifeworlds.

Perspectives on team communication challenges in caring for children with medical complexity

BACKGROUND

Children with medical complexity (CMC) require the expertise of many care providers spanning different disciplines, institutions, and settings of care. This leads to duplicate health records, breakdowns in communication, and limited opportunities to provide comprehensive, collaborative care. The objectives of this study were to explore communication challenges and solutions/recommendations from multiple perspectives including (i) parents, (ii) HCPs - hospital and community providers, and (iii) teachers of CMC with a goal of informing patient care.

METHODS

This qualitative study utilized an interpretive description methodology. In-depth semi-structured interviews were conducted with parents and care team members of CMC. The interview guides targeted questions surrounding communication, coordination, access to information and roles in the health system. Interviews were conducted until thematic saturation was reached. Interviews were audio-recorded, transcribed verbatim, and coded and analyzed using thematic analysis.

RESULTS

Thirty-two individual interviews were conducted involving parents (n = 16) and care team members (n = 16). Interviews revealed 2 main themes and several associated subthemes (in parentheses): (1) Communication challenges in the care of CMC (organizational policy and technology systems barriers, inadequate access to health information, and lack of partnership in care) (2) Communication solutions (shared systems that can be accessed in real-time, universal access to health information, and partnered contribution to care).

CONCLUSION

Parents, HCPs, and teachers face multiple barriers to communication and information accessibility in their efforts to care for CMC. Parents and care providers in this study suggested potential strategies to improve communication including facilitating communication in real-time, universal access to health information and meaningful partnerships.

Improving community-based care for children with a rare condition: The example of long-segment congenital tracheal stenosis and perceptions of health professionals, parents and teachers

BACKGROUND

Long segment congenital tracheal stenosis (LSCTS) is a rare, complex condition which is often poorly understood by community-based health professionals (HPs). Anecdotally, such HPs often lack confidence providing care for children, resulting in children being brought to the tertiary centre more frequently than necessary. We wanted to identify the information and support needs of HPs in primary and secondary care looking after a child with LSCTS, the views of those providing education to these children, and elicit parents' perceptions about community-based services, to improve overall care for children and families.

METHOD

Questionnaires were sent to 175 community-based HPs and 34 teachers involved in the care of children with LSCTS. Face-to-face or telephone interviews were conducted with 12 parents of patients with LSCTS to establish their perceptions of community-based services.

RESULTS

Ninety (51%) completed questionnaires were returned from HPs and 18 (53%) from teachers. Responses indicated low levels of knowledge of LSCTS. Physical, practical and communication information needs were identified by all respondent groups, together with general and condition-specific concerns. Interviews with parents indicated that they thought the level of knowledge about LSCTS in the community was low, which had a negative impact on their willingness to consult local services. Better information provision for HPs, teachers and parents was identified as a means of improving outcomes.

CONCLUSION

Professionals caring for children with LSCTS in the community and in schools have unmet information and support needs, with consequences for children, families, HCPs in both the community and tertiary hospital, and teachers.

Does participation in ethics discussions have an impact on ethics decision-making? A cross-sectional study among healthcare professionals in paediatric oncology

PURPOSE

The overall aim of this study was to describe perceptions of the decision-making process in relation to participation/non-participation in ethics discussions among healthcare professionals in paediatric oncology.

METHODS

Healthcare professionals, working at three paediatric units where ethics discussions where performed answered a study-specific questionnaire focusing on perceptions of involvement, influence, responsibility and understanding of ethics decision-making. Statistical analyses included descriptive statistics, non-parametric paired t-tests and correlation tests.

RESULTS

Participation in ethics discussions was related to perceptions of greater involvement and the possibility of influencing decisions, as well as formal/shared responsibility for the ethics decisions related to patient care. Medical doctors and registered nurses perception of involvement in decisions, possibility to influence and responsibility decreased when they were not present during the ethics discussion or when no ethics discussion was conducted at all. Healthcare professionals had a generally good understanding of the ethical issues and the ethics decisions. The whole group considered medical doctors to be the most important participants in the ethics discussions, followed by patients/family. Healthcare professionals wanted more teamwork and viewed ethics discussions as very helpful for teamwork when dealing with ethical issues in paediatric oncology.

CONCLUSIONS

Ethics discussions in paediatric oncology practice increases the involvement within and the understanding of the decision-making process about ethical decisions. The understanding is not always dependent on participation, indicating a great trust in team members. Based on these findings the implementation of a structure for ethics support in paediatric oncology where patients/families are integrated is recommended.

Understanding Gaps Between Daily Living and Clinical Settings in Chronic Disease Management: Qualitative Study

BACKGROUND

Management of chronic conditions entails numerous activities in both clinical and daily living settings. Activities across these settings interact, creating a high potential for a gap to occur if there is an inconsistency or disconnect between controlled clinical settings and complex daily living environments.

OBJECTIVE

The aim of this study is to characterize gaps (from the patient's perspective) between health-related activities across home-based and clinical settings using anticoagulation treatment as an example. The causes, consequences, and mitigation strategies (reported by patients) were identified to understand these gaps. We conceptualized gaps as latent phenomena (ie, a break in continuity).

METHODS

Patients (n=39) and providers (n=4) from the anticoagulation clinic of an urban, western mountain health care system were recruited. Data were collected through primary interviews with patients, patient journaling with tablet computers, exit interviews with patients, and provider interviews. Data were analyzed qualitatively using a theory-driven approach and framework method of analysis.

RESULTS

The causes of gaps included clinician recommendations not fitting into patients' daily routines, recommendations not fitting into patients' living contexts, and information not transferred across settings. The consequences of these gaps included increased cognitive and physical workload on the patient, poor patient satisfaction, and compromised adherence to the therapy plan. We identified resources and strategies used to overcome these consequences as patient-generated strategies, routines, collaborative management, social environment, and tools and technologies.

CONCLUSIONS

Understanding gaps, their consequences, and mitigating strategies can lead to the development of interventions that help narrow these gaps. Such interventions could take the form of collaborative health information technologies, novel patient and clinician education initiatives, and programs that strongly integrate health systems and community resources. Current technologies are insufficient to narrow the gaps between clinical and daily living settings due to the limited number and types of routines that are tracked.

Providing person-centered care for patients with complex healthcare needs: A qualitative study

Background

People with chronic conditions have complex healthcare needs that lead to challenges for adequate healthcare provision. Current healthcare services do not always respond adequately to their needs. A modular perspective, in particular providing visualization of the modular service architecture, is promising for improving the responsiveness of healthcare services to the complex healthcare needs of people with chronic conditions. The modular service architecture provides a comprehensive representation of the components and modules of healthcare provision. In this study, we explore this further in a qualitative multiple case study on healthcare provision for children with Down syndrome in the Netherlands.

Methods

Data collection for four cases involved 53 semi-structured interviews with healthcare professionals and 21 semi-structured interviews with patients (the parents of children with Down syndrome as proxy). In addition, we gathered data by means of practice observations and analysis of relevant documents. The interviews were audio-recorded, transcribed verbatim and analyzed utilizing the Miles and Huberman approach.

Results

Our study shows that the perspectives on healthcare provision of professionals and patients differ substantially. The visualization of the modular service architecture that was based on the healthcare professionals’ perspective provided a complete representation of (para)medical outcomes relevant to the professionals’ own discipline. In contrast, the modular service architecture based on the patients’ perspective, which we define as a person-centered modular service architecture, provided a representation of the healthcare service that was primarily based on functional outcomes and the overall wellbeing of the patients.

Conclusion

Our study shows that visualization of the modular service architecture can be a useful tool to better address the complex needs and requirements of people with a chronic condition. We suggest that a person-centered modular service architecture that focuses on functional outcomes and overall wellbeing, enables increased responsiveness of healthcare services to people with complex healthcare needs and provision of truly person-centered care.

Caring for Maya: A Family, Pediatrician, and Complex Care Partnership

Coordinating care to meet the robust needs of children with medical complexity and their families is challenging, especially in the setting of a busy primary care practice. This article describes the experience of one family and pediatrician and highlights specific factors, such as a focus on building relationships, meaningful and structured information-sharing, and partnership with a complex care program, that can positively affect care. [Pediatr Ann. 2020;49(11):e486-e490.].

[A study of paediatric patients with complex chronic conditions admitted to a paediatric department over a 12 month period]

INTRODUCTION

The number of patients with complex chronic conditions (CCC) has increased in the last 20 years or so. There is limited data as regards the prevalence of CCC in the paediatric population and its impact on hospital admissions. The main objectives of this study are to determine the proportion of CCC in the paediatric hospital population and compare them with other groups of patients admitted (acute and chronic).

PATIENTS AND METHODS

A descriptive, retrospective study was carried out in a tertiary maternity-paediatric hospital (from December 2016 to November 2017). All patients admitted into the Paediatric Department were recruited with a fortnightly frequency. A series of demographic, clinical, and pregnancy data were collected. In order to identify the level of complexity of the patients, the Clinical Risk Group (CRG) was used, with 3groups being created: acute, chronic, and CCC. Statistics analysis was performed using SPSS v24.

RESULTS

A total of 1,433 patients were included. The proportion of CCC on the Paediatric Ward was 14.4%. The CCC were older patients, mainly admitted due to decompensation or progression of their underlying disease, had a longer admission time, and required support in the Paediatric Intensive Care Unit more often than that of the other sub-groups. Just under half (44.7%) of the CCC were carriers of a technological device. Of the total of long stays (>1 month), 71.3% had CCC.

CONCLUSIONS

Patients with CCC require long hospital stays, a greater need of intensive care, and use of technology. New approaches to treatment and follow-up need to be established. They should be cost-effective, and at the same time decrease the impact of the disease on the children and their family.

Experiences of youth with medical complexity and their families during the transition to adulthood: a meta-ethnography

Youth with medical complexity (YMC) are a small subset of youth who have a combination of severe functional limitations and extensive health service use. As these youth become adults, they are required to transition to adult health, education, and social services. The transition to adult services is especially difficult for YMC due to the sheer number of services that they access. Service disruptions can have profound impacts on YMC and their families, potentially leading to an unsuccessful transition to adulthood. This meta-ethnography aims to synthesize qualitative literature exploring how YMC and their families experience the transition to adulthood and transfer to adult services. An in-depth understanding of youth and family experiences can inform interventions and policies to optimize supports and services to address the needs of this population at risk for unsuccessful transition to adulthood. Using Noblit and Hare’s approach to meta-ethnography, a comprehensive search of Medline, CINAHL, Embase, PsycINFO, Social Sciences Index, and Sociological Abstracts databases, supplemented by hand searching, was conducted to identify relevant studies. Included studies focused on the transition to adulthood or transfer to adult services for YMC, contained a qualitative research component, and had direct quotes from youth or family participants. Studies were critically appraised, and data were analyzed using meta-ethnographic methods of reciprocal translation and line of argument synthesis. Conceptual data from ten studies were synthesized into six overarching constructs: (1) the nature and process of transition, (2) changing relationships, (3) goals and expectations, (4) actions related to transition, (5) making sense of transition, and (6) contextual factors impacting transition. A conceptual model was developed that explains that youth and families experience dynamic interactions between their goals, actions, and relationships, which are bounded and influenced by the nature, process, and context of transition. Despite the tremendous barriers faced during transition, YMC and their families often demonstrate incredible resilience, perseverance, and resourcefulness in the pursuit of their goals. Implications for how the conceptual model can inform practice, policy, and research are shared. These implications include the need to address emotional needs of youth and families, support families in realizing their visions for the future, promote collaboration among stakeholders, and develop policies to incentivize and support providers in implementing current transition guidelines.

What Do Parents Expect in the 21st Century? A Qualitative Analysis of Integrated Youth Care

Introduction:

To provide integrated Youth Care responsive to the needs of families with multiple problems across life domains, it is essential to incorporate parental perspectives into clinical practice. The aim of this study is to advance our understanding of key components of integrated Youth Care from a parental perspective.

Methods:

Semi-structured interviews were administered to 21 parents of children receiving Youth Care from integrated care teams in the Netherlands. Qualitative content analysis was conducted by means of a grounded theory approach following qualitative reporting guidelines.

Results and discussion:

Parental perspectives were clustered into six key components: a holistic, family-centred approach; addressing a broad range of needs in a timely manner; shared decision making; interprofessional collaboration; referral; and privacy. Parents emphasized the importance of a tailored, family-centred approach, addressing needs across several life domains, and active participation in their own care process. However, they simultaneously had somewhat opposing expectations regarding these key components, for example, concerning the changing roles of professionals and parents in shared decision making and the value of involving family members in a care process. Professionals should be aware of these opposing expectations by explicitly discussing mutual expectations and changing roles in decision making during a care process. To enable parents to make their own decisions, professionals should transparently propose different options for support guided by an up-to-date care plan.

The Complexities of Everyday Life and Healthcare Utilization in Danish Children With ADHD: A Mixed Methods Study

PURPOSE

To explore and describe everyday life and hospital-based healthcare experiences and utilization in families of children with ADHD in Denmark.

DESIGN AND METHODS

The present work is a multistage, mixed methods study. The design consists of three individual studies: a meta-synthesis, a focused ethnographic study, and a historical cohort study.

RESULTS

The integrated findings show that: 1) parental stressors affect everyday life and hospital-based service use; 2) parents have concerns for their child from early childhood and fight to have their concerns recognized; and 3) healthcare professionals are important for parents to navigate the persistent challenges of everyday life.

CONCLUSIONS

Having a child with ADHD pervades everyday life and children with ADHD use more medical and psychiatric services in hospitals during the first 12 years of life than children without ADHD. The findings demonstrate a vulnerable everyday life experience and highlight the importance of the families being recognized, accepted, and respected in hospital-based healthcare services from early childhood.

PRACTICE IMPLICATIONS

Healthcare professionals need to recognize the challenges the family of a child with ADHD faces and to acknowledge that ADHD pervades all aspects of everyday life and all other healthcare issues. It is important for healthcare professionals, regardless of specialty, to engage with individual families and to positively contribute to the medical and psychiatric healthcare experience.

Who needs and continues to need paediatric palliative care? An evaluation of utility and feasibility of the Paediatric Palliative Screening scale (PaPaS)

Background

While the populations of children who can benefit from paediatric palliative care (PPC) have been broadly defined, identifying individual patients to receive PPC has been problematic in practice. The Paediatric Palliative Screening scale (PaPaS) is a multi-dimensional tool that assesses palliative care needs in children and families to facilitate timely referrals. This study evaluates its use to manage new referrals and ongoing review of patients receiving home-based PPC in Singapore.

Methods

Using a retrospective cohort study design, 199 patients admitted to receive PPC via clinician screening were scored using PaPaS. Eighty-four patients in two groups were scored again at one of two following milestones: one-year service continuation mark or point of discharge before a year. Accuracy measures were compared against clinical assessment.

Results

96.98% of patients scored 15 and above on admission (indicating need for PPC). Patients assessed at following milestones were effectively stratified; those who continued to receive service after 1 year scored significantly higher (M = 19.23) compared to those who were discharged within a year (M = 7.86). Sensitivity and specificity for PaPaS were calculated at 82.54 and 100% respectively. Overall congruence with clinician-based decisions supports the utility of PaPaS as a screening tool in PPC. Recommendations to improve the scale further are proposed.

Conclusion

The PaPaS is a practical screening tool that signposts PPC needs within the clinical setting. This facilitates early referrals to PPC, without having to specify individual prognoses that are often uncertain. Other benefits include optimised continuity of care and implications for resource allocation.

Living with epidermolysis bullosa: Daily challenges and health-care needs

BACKGROUND & OBJECTIVE

Epidermolysis bullosa (EB) is the term used for a group of genetic skin fragility disorders. For those living with EB, pain represents a constant challenge, with blistering and tasks such as changing dressings, adding to the distress. This paper focuses on describing and exploring the health-care needs of children, adults and families who are affected by EB. The specific aim of the paper is to identify the needs of the EB population with a view towards informing the development of a community liaison service to support adults living with EB and the parents/carers of children living with EB.

SETTING AND PARTICIPANTS

Interviews with six adults and the parents of eight children with EB were conducted. The data were analysed thematically. All participants were resident on the island of Ireland and are therefore reflecting on services in this geographic region.

RESULTS

Participants' needs were grouped into five themes: support managing physical health-care issues; access to community/home-based services; EB-specific information and psychosocial support; effective interaction with health-care professionals; and advice regarding benefits and entitlements.

DISCUSSION AND CONCLUSIONS

This article represents the health-care needs and preferences of a broad spectrum of those with EB, highlighting the need for a comprehensive service regardless of the severity of the condition.

Quality of health care according to people with Down syndrome, their parents and support staff-A qualitative exploration

Background

People with Down syndrome (PDS) have complex healthcare needs. Little is known about the quality of health care for PDS, let alone how it is appraised by PDS and their caregivers. This study explores the perspectives of PDS, their parents and support staff regarding quality in health care for PDS.

Method

The present authors conducted semi‐structured interviews with 18 PDS and 15 parents, and focus groups with 35 support staff members (of PDS residing in assisted living facilities) in the Netherlands.

Results

According to the participants, healthcare quality entails well‐coordinated health care aligned with other support and care systems, a person‐centred and holistic approach, including respect, trust and provider–patient communication adapted to the abilities of PDS.

Conclusions

Our findings may be used to improve health care for PDS, and provide insight into how health care could match the specific needs of PDS.

Provider Networks in the Neonatal Intensive Care Unit Associate with Length of Stay

We strive to understand care coordination structures of multidisciplinary teams and to evaluate their effect on post-surgical length of stay (PSLOS) in the Neonatal Intensive Care Unit (NICU). Electronic health record (EHR) data were extracted for 18 neonates, who underwent gastrostomy tube placement surgery at the Vanderbilt University Medical Center NICU. Based on providers' interactions with the EHR (e.g. viewing, documenting, ordering), provider-provider relations were learned and used to build patient-specific provider networks representing the care coordination structure. We quantified the networks using standard network analysis metrics (e.g., in-degree, out-degree, betweenness centrality, and closeness centrality). Coordination structure effectiveness was measured as the association between the network metrics and PSLOS, as modeled by a proportional-odds, logistical regression model. The 18 provider networks exhibited various team compositions and various levels of structural complexity. Providers, whose patients had lower PSLOS, tended to disperse patient-related information to more colleagues within their network than those, who treated higher PSLOS patients (P = 0.0294). In the NICU, improved dissemination of information may be linked to reduced PSLOS. EHR data provides an efficient, accessible, and resource-friendly way to study care coordination using network analysis tools. This novel methodology offers an objective way to identify key performance and safety indicators of care coordination and to study dissemination of patient-related information within care provider networks and its effect on care. Findings should guide improvements in the EHR system design to facilitate effective clinical communications among providers.

Patient Navigation as an Approach to Improve the Integration of Care: The Case of NaviCare/SoinsNavi

Children and youth with complex care needs require more and varied healthcare services than the average population, as well as a high degree of coordinated care. Evidence has shown that these individuals and their families have better outcomes if they have access to integrated care. Patient navigation can serve as a novel approach to improve the integration of care for individuals with complex care needs in an increasingly fragmented system. NaviCare/SoinsNavi is an example of a navigation centre for children and youth with complex care needs, their families, and the care team. This research-based service is aimed at facilitating more convenient and integrated care using a personalized family-centred approach. NaviCare/SoinsNavi employs two patient navigators who work with clients to formulate and prioritize goals based on their unmet needs. The centre serves as a living laboratory, which provides researchers, knowledge users, and clients a real life setting where innovative ideas can be explored, evaluated, modified as needed throughout the research process, and moved into policy in an efficient manner. Patient navigation programs can contribute to decreasing fragmentation, improving access, and promoting integrated care across disciplines, settings, and sectors for individuals across the lifespan.

Modelling collaboration of primary and secondary care for children with complex care needs: long-term ventilation as an example

Children dependent on long-term ventilation need the planning, provision and monitoring of complex services generally provided at home by professionals belonging to different care settings. The collaboration among professionals improves the efficiency and the continuity of care especially when treating children with complex care needs. In this paper, the Unified Modelling Language (UML) has been adopted to detect the variety of the patterns of collaboration as well as to represent and compare the different processes of care across the 30 EU/EEA countries of the MOCHA project.Conclusion: Half of the analysed countries have a multidisciplinary team with different degrees of team composition, influencing organisational features such as the development of the personalised plan as well as the provision of preventive and curative services. This approach provides indications on the efficiency in performing and organising the delivery of care in terms of family involvement, interactions among professionals and availability of ICT. What is known: • Children with CCNs require a coordination of efforts before and after discharge in a continuum of care delivery dependent on the level of integrated care solutions adopted at country level. What is new: •The adoption of a business process method contributes to perform a cross-country analysis highlighting the variability of team composition and its influence on the delivery of care. • This approach provides indications on the efficiency in performing and organising the delivery of care in terms of family involvement, interactions among professionals and availability of ICT.