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Brady PW, Ruddy RM, Ehrhardt J, Corathers SD, Kirkendall ES, Walsh KE. Assessing the Revised Safer Dx Instrument ® in the understanding of ambulatory system design changes for type 1 diabetes and autism spectrum disorder in pediatrics. Diagnosis (Berl) 2024; 11:266-272. [PMID: 38517065 PMCID: PMC11306753 DOI: 10.1515/dx-2023-0166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/27/2024] [Indexed: 03/23/2024]
Abstract
OBJECTIVES We sought within an ambulatory safety study to understand if the Revised Safer Dx instrument may be helpful in identification of diagnostic missed opportunities in care of children with type 1 diabetes (T1D) and autism spectrum disorder (ASD). METHODS We reviewed two months of emergency department (ED) encounters for all patients at our tertiary care site with T1D and a sample of such encounters for patients with ASD over a 15-month period, and their pre-visit communication methods to better understand opportunities to improve diagnosis. We applied the Revised Safer Dx instrument to each diagnostic journey. We chose potentially preventable ED visits for hyperglycemia, diabetic ketoacidosis, and behavioral crises, and reviewed electronic health record data over the prior three months related to the illness that resulted in the ED visit. RESULTS We identified 63 T1D and 27 ASD ED visits. Using the Revised Safer Dx instrument, we did not identify any potentially missed opportunities to improve diagnosis in T1D. We found two potential missed opportunities (Safer Dx overall score of 5) in ASD, related to potential for ambulatory medical management to be improved. Over this period, 40 % of T1D and 52 % of ASD patients used communication prior to the ED visit. CONCLUSIONS Using the Revised Safer Dx instrument, we uncommonly identified missed opportunities to improve diagnosis in patients who presented to the ED with potentially preventable complications of their chronic diseases. Future researchers should consider prospectively collected data as well as development or adaptation of tools like the Safer Dx.
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Affiliation(s)
- Patrick W. Brady
- Division of Hospital Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Richard M. Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Emergency Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Jennifer Ehrhardt
- Division of Development and Behavioral Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Sarah D. Corathers
- Division of Hospital Medicine, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital, Cincinnati, OH, USA
- Division of Endocrinology, Cincinnati Children’s Hospital, Cincinnati, OH, USA
| | - Eric S. Kirkendall
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
- Center for Healthcare Innovation, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Kathleen E. Walsh
- Department of General Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of General Pediatrics, Boston Children’s Hospital,, Boston, MA, USA
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Caregivers' experiences in the management of children with epilepsy: A Systematic synthesis of qualitative studies. Seizure 2023; 106:117-128. [PMID: 36827863 DOI: 10.1016/j.seizure.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 02/10/2023] Open
Abstract
OBJECTIVE Childhood is the prime age for epilepsy onset. Adults in the family of affected children often become caregivers. Providing care for children with epilepsy may affect the caregivers' quality of life. There is a paucity of literature reviewing the experiences of caregivers of children with epilepsy. Therefore, we summarised the best available evidence exploring caregivers' experiences in caring for children with epilepsy. METHOD Published papers in PubMed, CINAHL, Embase, Cochrane Library, Web of Science, Scopus, and PsycINFO databases were identified by two researchers. All search results were imported into EndNote X20. Two reviewers independently extracted the data using Microsoft Excel. The Critical Appraisal Skill Program systematic review checklist was used to evaluate the quality of the included articles. Data of the included studies were extracted by two independent reviewers using a standardised form. These findings were synthesised using a meta-aggregative approach. RESULTS A total of 12 studies were included in this meta-synthesis. In total, 260 findings were identified. These findings were aggregated into 13 categories, which were synthesised into four main themes: (i) burden experienced by caregivers, (ii) challenges experienced by caregivers, (iii) lack of social support, and (iv) adaptation to disease conditions. SIGNIFICANCE The synthesised studies present multiple perspectives on the burdens and challenges encountered by caregivers of children with epilepsy. Caregivers require support from a variety of sources, not only from their families but also society at large. Providing care to children with epilepsy is a dynamic experience for caregivers.
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3
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Schnell JL, Johaningsmeir S, Bartelt T, Bergman DA. Partnering with Parents of Children with Medical Complexity: A Framework for Engaging Families for Practice Improvement. Pediatr Ann 2020; 49:e467-e472. [PMID: 33170294 DOI: 10.3928/19382359-20201012-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The role of patients and families has evolved over the years, from being viewed as entities who were told what to do, to consumers of health services, to being central to health system design and clinical decision-making. When designing health care practices and programs to be patient- and family-centered, we believe that parents of children with medical complexity (CMC) bring valuable viewpoints and experiences to the table. Good health and functional outcomes for CMC and their families are dependent on active family engagement with their health care partners. We apply the Patient Engagement in Redesigning Care Toolkit (PERCT) model to describe the experience of complex care programs with engaging families at various levels of program design and function, including strengths and pitfalls experienced with each PERCT category. Operationalizing the health care system to treat patients and families as equal stakeholders is necessary if we want to succeed in a patient-centered, value-based environment. [Pediatr Ann. 2020;49(11):e467-e472.].
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Michel HK, Siripong N, Noll RB, Kim SC. Caregiver and Adolescent Patient Perspectives on Comprehensive Care for Inflammatory Bowel Diseases: Building a Family-Centered Care Delivery Model. CROHN'S & COLITIS 360 2020; 2:otaa055. [PMID: 32851385 PMCID: PMC7437716 DOI: 10.1093/crocol/otaa055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Children with inflammatory bowel diseases (IBDs) require primary and gastrointestinal (GI) care, but little is known about patient and family preferences for care receipt. We aimed to understand caregiver perceptions of current healthcare quality, describe barriers to receiving healthcare, and elicit caregiver and adolescent preferences for how comprehensive care ideally would be delivered. METHODS This was an anonymous survey of caregivers of 2- to 17-year olds with IBD and adolescents with IBD aged 13-17 years at a large, free-standing children's hospital. Surveys assessed patient medical history, family demographics, perceptions of health care quality and delivery, barriers to primary and GI care, and preferences for optimal care delivery. RESULTS Two hundred and seventeen caregivers and 140 adolescents were recruited, 214 caregivers and 133 adolescents consented/assented, and 160 caregivers and 84 adolescents completed the survey (75% and 60% response rate, respectively). Mean patient age was 14 years (SD = 3); 51% male; 79% Crohn's disease, 16% ulcerative colitis, and 4% indeterminate colitis. Caregivers were primarily female (86%), Caucasian (94%), and living in a 2-caregiver household (79%). Most caregivers reported that their child's primary care physician (PCP) and GI doctor oversaw their primary care (71%) and their IBD care (94%), respectively. Caregivers were satisfied with communication with their PCP and GI providers (>90%) but did not know how well they communicated with one another (54%). Barriers to primary and GI care varied, and few caregivers (6%) reported unmet healthcare needs. Caregivers and adolescents saw PCPs and GI doctors having important roles in comprehensive care, though specific preferences for care delivery differed. CONCLUSION Caregivers and adolescent perspectives are essential to developing family-centered care models for children with IBD.
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Affiliation(s)
- Hilary K Michel
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Nalyn Siripong
- Clinical Translational Science Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert B Noll
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sandra C Kim
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center (UPMC) Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Connected Subspecialty Care: Applying Telehealth Strategies to Specific Referral Barriers. Acad Pediatr 2020; 20:16-22. [PMID: 31404707 PMCID: PMC6944761 DOI: 10.1016/j.acap.2019.08.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 07/21/2019] [Accepted: 08/02/2019] [Indexed: 10/26/2022]
Abstract
Nearly a quarter of families of children with need of subspecialty care report difficulty accessing that care. Telehealth is a method to overcome barriers to subspecialty care. However, improving access to subspecialty care through telehealth requires granular identification of specific subspecialty barriers and recognition of the strengths and limitations of each telehealth strategy for addressing identified barriers. Focusing on each sequential step in subspecialty referrals and potential associated barriers, we summarize specific telehealth and technology-enabled strategies to improve access to subspecialty care, including electronic consultations, live interactive telemedicine, store-and-forward telemedicine, tele-mentoring, patient portals, and remote patient monitoring. Intentionally selecting telehealth strategies to target specific subspecialty referral barriers may avoid risks from misapplication of telehealth, may more clearly elevate equitable access as an essential goal within telehealth initiatives, and may also lead to synergistic use of strategies that overcome sequential barriers.
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7
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Savoy A, Patel H, Flanagan ME, Daggy JK, Russ AL, Weiner M. Comparative usability evaluation of consultation order templates in a simulated primary care environment. APPLIED ERGONOMICS 2018; 73:22-32. [PMID: 30098639 DOI: 10.1016/j.apergo.2018.05.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/12/2018] [Accepted: 05/27/2018] [Indexed: 06/08/2023]
Abstract
Communication breakdowns in the referral process negatively impact clinical workflow and patient safety. There is a lack of evidence demonstrating the impact of published design recommendations addressing contributing issues with consultation order templates. This study translated the recommendations into a computer-based prototype and conducted a comparative usability evaluation. With a scenario-based simulation, 30 clinicians (referrers) participated in a within-group, counterbalanced experiment comparing the prototype with their present electronic order entry system. The prototype significantly increased satisfaction (Cohen's d = 1.80, 95% CI [1.19, 2.41], p < .001), and required significantly less mental effort (d = 0.67 [0.14, 1.20], p < .001). Regarding efficiency, the prototype required significantly fewer mouse clicks (mean difference = 29 clicks, p < .001). Although overall task time did not differ significantly (d = -0.05 [-0.56, 0.47]), the prototype significantly quickened identification of the appropriate specialty clinic (mean difference = 12 s, d = 0.98 [0.43, 1.52], p < .001). The experimental evidence demonstrated that clinician-centered interfaces significantly improved system usability during ordering of consultations.
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Affiliation(s)
- April Savoy
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA;; Regenstrief Institute, Inc., Indianapolis, IN, USA; School of Business and Economics, Indiana University East, Richmond, IN, USA.
| | - Himalaya Patel
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA
| | | | - Joanne K Daggy
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alissa L Russ
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA;; Regenstrief Institute, Inc., Indianapolis, IN, USA; College of Pharmacy, Purdue University, West Lafayette, IN, USA
| | - Michael Weiner
- Center for Health Information and Communication, Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service, CIN 13-416, Richard L. Roudebush VA Medical Center, Indianapolis, IN, USA;; Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA
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Patient, Primary Care Provider, and Specialist Perspectives on Specialty Care Coordination in an Integrated Health Care System. J Ambul Care Manage 2018; 41:15-24. [PMID: 29176459 DOI: 10.1097/jac.0000000000000219] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Successful coordination of specialty care requires understanding the perspectives of patients, primary care providers, and specialists-that is, the specialty care "triad." This study used qualitative methods to compare these perspectives in an integrated health care system, using diabetes specialty care as an exemplar. Primary care providers and endocrinologists relied on interclinician relationships to coordinate care. Clinicians rarely included patients or other staff in their conceptualization of specialty care coordination. Patients often assumed responsibility for specialty care coordination but struggled to succeed. We identified several opportunities to improve coordination across the triad. In an integrated medical system, the shared organizational structure can facilitate these efforts.
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Muradian S, Widge A, Hanson JL, Lane JL, Boogaard C, Agrawal D, Ottolini M, Hamburger EK. Tools for Learning About the Referral and Consultation Process for Pediatric Residents. Acad Pediatr 2018; 18:357-359. [PMID: 29408680 DOI: 10.1016/j.acap.2018.01.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 01/16/2018] [Accepted: 01/23/2018] [Indexed: 10/18/2022]
Abstract
Management of referral and consultation is an entrustable professional activity for pediatric residents; however, few tools exist to teach these skills. We designed and implemented tools to prompt discussion, feedback, and reflection about the process of referral, notably including the family's perspective.
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Affiliation(s)
- Sarah Muradian
- Office of Medical Education, Children's National Medical System, George Washington University School of Medicine, Washington, DC
| | - Alicia Widge
- Office of Medical Education, Children's National Medical System, George Washington University School of Medicine, Washington, DC
| | - Janice L Hanson
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - J Lindsey Lane
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo
| | - Claire Boogaard
- Office of Medical Education, Children's National Medical System, George Washington University School of Medicine, Washington, DC
| | - Dewesh Agrawal
- Office of Medical Education, Children's National Medical System, George Washington University School of Medicine, Washington, DC
| | - Mary Ottolini
- Office of Medical Education, Children's National Medical System, George Washington University School of Medicine, Washington, DC
| | - Ellen K Hamburger
- Office of Medical Education, Children's National Medical System, George Washington University School of Medicine, Washington, DC.
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10
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Kurahashi AM, Stinson JN, van Wyk M, Luca S, Jamieson T, Weinstein P, Cafazzo JA, Lokuge B, Cohen E, Rapoport A, Husain A. The Perceived Ease of Use and Usefulness of Loop: Evaluation and Content Analysis of a Web-Based Clinical Collaboration System. JMIR Hum Factors 2018; 5:e2. [PMID: 29317386 PMCID: PMC5780614 DOI: 10.2196/humanfactors.7882] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/27/2017] [Accepted: 11/16/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Patients with complex health care needs require the expertise of many health care providers. Communication, collaboration, and patient-centered care positively impact care quality and patient outcomes. Few technologies exist that facilitate collaboration between providers across settings of care and also engage the patient. We developed a Web-based clinical collaboration system, Loop, to address this gap. The likelihood of a technological system's uptake is associated with its perceived ease of use and perceived usefulness. We engaged stakeholders in the conceptualization and development of Loop in an effort to maximize its intuitiveness and utility. OBJECTIVE This study aimed to report end users' perceptions about the ease of use and usefulness of Loop captured during usability tests of Loop. METHODS Participants represented three user types (patients, caregivers, and health care providers) recruited from three populations (adults with cancer, adolescents and young adults with cancer, and children with medical complexity). We conducted usability testing over three iterative cycles of testing and development in both laboratory-based and off-site environments. We performed a content analysis of usability testing transcripts to summarize and describe participant perceptions about the ease of use and usefulness of Loop. RESULTS Participants enjoyed testing Loop and were able to use the core functions-composing, posting, and reading messages-with little difficulty. They had difficulty interpreting certain visual cues and design elements or the purpose of some features. This difficulty negatively impacted perceived ease of use but was primarily limited to auxiliary features. Participants predicted that Loop could improve the efficiency and effectiveness of communication between care team members; however, this perceived usefulness could be compromised by disruptions to personal workflow such as additional time or task requirements. CONCLUSIONS Loop was perceived to have value as a collaboration system; however, usability testing findings indicate that some design and functional elements need to be addressed to improve ease of use. Additionally, participant concerns highlight the need to consider how a system can be implemented so as to minimize impact on workflow and optimize usefulness.
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Affiliation(s)
- Allison M Kurahashi
- The Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Jennifer N Stinson
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Margaret van Wyk
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Stephanie Luca
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada
| | - Trevor Jamieson
- Division of General Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Weinstein
- Healthcare Human Factors, Techna Institute, University Health Network, Toronto, ON, Canada
| | - Joseph A Cafazzo
- Healthcare Human Factors, Techna Institute, University Health Network, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute of Biomaterials and Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Bhadra Lokuge
- The Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada
| | - Eyal Cohen
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
| | - Adam Rapoport
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada.,Emily's House Children's Hospice, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Amna Husain
- The Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Ray KN, Drnach M, Mehrotra A, Suresh S, Docimo SG. Impact of Implementation of Electronically Transmitted Referrals on Pediatric Subspecialty Visit Attendance. Acad Pediatr 2018; 18:409-417. [PMID: 29277463 PMCID: PMC5936662 DOI: 10.1016/j.acap.2017.12.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/10/2017] [Accepted: 12/16/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE One barrier to timely access to outpatient pediatric subspecialty care is the complexity of scheduling processes. We evaluated the impact of implementing electronically transmitted referrals on subspecialty visit attendance. METHODS Through collaboration with stakeholders, an electronically transmitted referral order system was designed, piloted, and implemented in 15 general pediatrics practices, with 24 additional practices serving as controls. We used statistical process control methods and difference-in-differences analysis to examine visits attended, appointments scheduled, appointment nonattendance, and referral volume. Electronically transmitted referrals then were expanded to all 39 practices. We surveyed referring pediatricians at all practices before and after implementation. RESULTS From April 2015 through September 2016 there were 33,485 referral orders across all practices (7770 before the pilot, 11,776 during the pilot, 13,939 after full implementation). At pilot practices, there was a significant and sustained improvement in subspecialty visits attended within 4 weeks of referral (10.9% to 20.0%; P < .001). Relative to control practices, pilot practices experienced an 8.6% improvement (P = .001). After implementation at control practices, rates of visits attended also improved but to a smaller degree: 11.8% to 14.7% (P < .001). In survey responses, referring pediatricians noted improved scheduling processes but had continued concerns with appointment availability and referral tracking. CONCLUSIONS While electronically transmitted referrals improved visit attendance after pediatric subspecialty referral, the sizable percentage of children without attended visits, the muted effect at control practices, and pediatrician survey responses indicate that additional work is needed to address barriers to pediatric subspecialty care.
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12
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Harahsheh AS, O’Byrne ML, Pastor B, Graham DA, Fulton DR. Pediatric Chest Pain-Low-Probability Referral: A Multi-Institutional Analysis From Standardized Clinical Assessment and Management Plans (SCAMPs®), the Pediatric Health Information Systems Database, and the National Ambulatory Medical Care Survey. Clin Pediatr (Phila) 2017; 56:1201-1208. [PMID: 28081617 PMCID: PMC6388765 DOI: 10.1177/0009922816684605] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We conducted a study to assess test characteristics of red-flag criteria for identifying cardiac disease causing chest pain and technical charges of low-probability referrals. Accuracy of red-flag criteria was ascertained through study of chest pain Standardized Clinical Assessment and Management Plans (SCAMPs®) data. Patients were divided into 2 groups: Group1 (concerning clinical elements) and Group2 (without). We compared incidence of cardiac disease causing chest pain between these 2 groups. Technical charges of Group 2 were analyzed using the Pediatric Health Information System database. Potential savings for the US population was estimated using National Ambulatory Medical Care Survey data. Fifty-two percent of subjects formed Group 1. Cardiac disease causing chest pain was identified in 8/1656 (0.48%). No heart disease was identified in patients in Group 2 ( P = .03). Applying red-flags in determining need for referral identified patients with cardiac disease causing chest pain with 100% sensitivity. Median technical charges for Group 2, over a 4-year period, were US2014$775 559. Eliminating cardiac testing of low-probability referrals would save US2014$3 775 182 in technical charges annually. Red-flag criteria were an effective screen for children with chest pain. Eliminating cardiac testing in children without red-flags for referral has significant technical charge savings.
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Affiliation(s)
- Ashraf S Harahsheh
- Department of Pediatrics- Division of Cardiology, Children’s National Health System/ George Washington University School of Medicine and Health Sciences, 111 Michigan Ave, N.W. Washington, DC 20010
| | - Michael L O’Byrne
- Department of Pediatrics- Division of Cardiology, Children’s National Health System/ George Washington University School of Medicine and Health Sciences, 111 Michigan Ave, N.W. Washington, DC 20010
| | - Bill Pastor
- Performance Improvement, Children’s National Health System, 111 Michigan Ave, N.W. Washington, DC 20010
| | - Dionne A. Graham
- Institute for Relevant Clinical Data Analytics and Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave. Boston, MA 02115
| | - David R. Fulton
- Department of Cardiology, Boston Children’s Hospital, Harvard Medical School, 300 Longwood Ave. Boston, MA 02115
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13
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Stille CJ, Honigfeld L, Heitlinger LA, Kuo DZ, Werner EJ. The Pediatric Primary Care-Specialist Interface: A Call For Action. J Pediatr 2017; 187:303-308. [PMID: 28595768 DOI: 10.1016/j.jpeds.2017.04.054] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/20/2017] [Accepted: 04/24/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher J Stille
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
| | | | - Leo A Heitlinger
- St Luke's Pediatric Gastroenterology, St Luke's University Hospital, Bethlehem, PA; Clinical Professor of Pediatrics, Temple University School of Medicine, Philadelphia, PA
| | - Dennis Z Kuo
- Department of Pediatrics, University at Buffalo, Buffalo, NY
| | - Eric J Werner
- Division of Pediatric Hematology/Oncology, Eastern Virginia Medical School, Norfolk, VA
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14
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deJong NA, Dellon EP, Vander Schaaf EB, Stiles AD, Carr RA, Steiner MJ. Enhanced Access and Parents' Preferred Contact for a Child's Chronic Condition. J Pediatr 2017; 180:235-240.e1. [PMID: 27742127 DOI: 10.1016/j.jpeds.2016.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 07/18/2016] [Accepted: 09/06/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess whether the perception of enhanced access by parents in their child's primary care and main specialty practices is associated with preference for contacting either practice when problems arise with a child's chronic condition. STUDY DESIGN In this cross-sectional survey study of parents whose children use both primary and specialty practices, we assessed perceptions of 3 components of enhanced access: (1) appointment availability when needed, (2) electronic communication with practices, and (3) other staff that help manage a child's health care needs. Parents also indicated which practice they would contact for an exacerbation of the main chronic condition for which the child receives specialty care. We used logistic regression to examine relationships of enhanced access components in both practices with parents' indicated practice. RESULTS Among 609 parents, 244 (40%) would contact primary care and 365 (60%) the main specialty practice for a chronic condition exacerbation. Although parents perceived enhanced access components with similar frequency in both settings, enhanced access was associated only with preference for contacting the main specialty practice: e-mail communication (aOR for preferring the specialty practice 2.0 [1.3, 3.2]) and staff that coordinate a child's care needs (aOR 2.8 [1.4, 5.9]). CONCLUSIONS Enhanced access is associated with preference for addressing chronic condition exacerbations in specialty but not primary care. Future study should further identify factors important to parents in deciding when and how to contact practices and should seek to develop family-centered communication within medical homes that integrate primary and specialty care.
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Affiliation(s)
- Neal A deJong
- Division of General Pediatrics and Adolescent Medicine, UNC School of Medicine, Chapel Hill, NC.
| | - Elisabeth P Dellon
- Division of Pediatric Pulmonology, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Emily B Vander Schaaf
- Division of General Pediatrics and Adolescent Medicine, UNC School of Medicine, Chapel Hill, NC
| | - Alan D Stiles
- University of North Carolina Health Care System, Chapel Hill, NC
| | - Rachael A Carr
- University of North Carolina Health Care System, Chapel Hill, NC
| | - Michael J Steiner
- Division of General Pediatrics and Adolescent Medicine, UNC School of Medicine, Chapel Hill, NC
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15
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Ray KN, Ashcraft LE, Kahn JM, Mehrotra A, Miller E. Family Perspectives on High-Quality Pediatric Subspecialty Referrals. Acad Pediatr 2016; 16:594-600. [PMID: 27237115 PMCID: PMC4975949 DOI: 10.1016/j.acap.2016.05.147] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Although children are frequently referred to subspecialist physicians, many inadequacies in referral processes have been identified from physician and system perspectives. Little is known, however, about how to comprehensively measure or improve the quality of the referral systems from a family-centered perspective. To foster family-centered improvements to pediatric subspecialty referrals, we sought to develop a framework for high-quality, patient-centered referrals from the perspectives of patients and their families. METHODS We used stakeholder-informed qualitative analysis of parent, caregiver, and patient interviews to identify outcomes, processes, and structures of high-quality pediatric subspecialty referrals as perceived by patients and their family members. RESULTS We interviewed 21 informants. Informants identified 5 desired outcomes of subspecialty referrals: improved functional status or symptoms; improved long-term outcomes; improved knowledge of their disease; informed expectations; and reduced anxiety about the child's health status. Processes that informants identified as supporting these outcomes centered around 6 key steps in subspecialty referrals, including the referral decision, previsit information transfer, appointment scheduling, subspecialist visit, postvisit information transfer, and ongoing care integration and communication. Health care delivery structures identified by informants as supporting these processes included physical infrastructure, human resources, and information technology systems. CONCLUSIONS We identified family-centered outcomes, processes, and structures of high-quality pediatric subspecialty referrals. These domains can be used not only to improve measurement of the quality of existing referral systems but also to inform future interventions to improve patient-centered outcomes for children in need of specialty care.
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Affiliation(s)
- Kristin N. Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, 3414 Fifth Avenue, Pittsburgh, Pennsylvania, 15213
| | - Laura Ellen Ashcraft
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 601B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261
| | - Jeremy M. Kahn
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, 601B Scaife Hall, 3550 Terrace Street, Pittsburgh, PA, 15261
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Ateev Mehrotra
- Department of Health Care Policy and Medicine, Harvard Medical School and RAND Corporation, 180 Longwood Avenue, Boston, Massachusetts, 02115
| | - Elizabeth Miller
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children’s Hospital of Pittsburgh, 3414 Fifth Avenue, Pittsburgh, Pennsylvania, 15213
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Bhansali P, Washofsky A, Romrell E, Birch S, Winer JC, Hoffner W. Parental Understanding of Hospital Course and Discharge Plan. Hosp Pediatr 2016; 6:449-55. [PMID: 27369094 DOI: 10.1542/hpeds.2015-0111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVES Hospital discharge marks an important transition in care from the inpatient team to the family and primary care provider. Parents must know the hospital course and discharge plan to care for their child at home and provide background for future providers. Our study aimed to determine parental knowledge of key aspects of their child's hospital course and discharge plan and to identify markers of increased risk for incomplete or incorrect knowledge among participants. METHODS We conducted a descriptive prospective cohort study of parents within 24 hours of hospital discharge. The primary outcome was concordance of parent responses to verbal interview questions about their child's hospital treatment, laboratory testing, imaging, procedures and discharge plan with the medical record. RESULTS Of 174 participants, 15% felt less than "completely prepared" to explain the hospital course to their primary care provider or to provide care after discharge. There was >83% overall concordance with interview responses and the medical record, with concordance higher for hospital course events than discharge plan. There were few significant differences in understanding between trainee-based teams and the attending physician-run unit. No patient or family characteristics were consistently associated with poor understanding of hospital course or discharge plan. CONCLUSIONS Although parents were generally knowledgeable about hospital course and discharge plan, areas for improved communication were identified. Individualized counseling about hospital course and discharge plan should be initiated for all parents early during hospitalization. Methods that assess and bolster caregiver comprehension and minimize dependence on written instructions may help with transition to outpatient care.
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Affiliation(s)
- Priti Bhansali
- Children's National Health System, Washington, District of Columbia; and
| | - Anne Washofsky
- Children's National Health System, Washington, District of Columbia; and
| | - Evan Romrell
- The George Washington School of Medicine and Health Sciences, Washington, District of Columbia
| | - Sarah Birch
- Children's National Health System, Washington, District of Columbia; and
| | - Jeffrey C Winer
- Children's National Health System, Washington, District of Columbia; and
| | - Wendy Hoffner
- Children's National Health System, Washington, District of Columbia; and
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O'Toole S, Benson A, Lambert V, Gallagher P, Shahwan A, Austin JK. Family communication in the context of pediatric epilepsy: A systematic review. Epilepsy Behav 2015; 51:225-39. [PMID: 26298868 DOI: 10.1016/j.yebeh.2015.06.043] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 06/06/2015] [Accepted: 06/29/2015] [Indexed: 01/27/2023]
Abstract
In childhood chronic illness, family communication can impact the child's and parents' psychosocial well-being. However, little is known about family communication in the context of epilepsy in childhood. The aim of this systematic review was to identify the existing evidence available on communication strategies adopted by families living with childhood epilepsy, including; the facilitators, barriers and challenges experienced by families when choosing to communicate, or not, about epilepsy; and the consequences of this communication. Papers published in the English language prior to March 2015 were identified following a search of six electronic databases: PubMed, MEDLINE, Web of Science, PsycINFO, CINAHL, and Scopus. Studies were included if they involved a sample of parents of children with epilepsy or children/young people with epilepsy (0-18years of age) and used qualitative, quantitative, or mixed methods. Following a comprehensive search and screening process, 26 studies were identified as eligible for inclusion in the review. No studies identified specific communication strategies adopted by families living with childhood epilepsy. Some studies found that talking about epilepsy with family members had positive consequences (e.g., communication as an effective coping strategy), with no negative consequences reported in any of the studies. The main barrier to communication for parents was an unwillingness to use the word "epilepsy" because of the perceived negative social connotations associated with the health condition. For children with epilepsy, barriers were as follows: parental desire to keep epilepsy a secret, parents' tendency to deny that the child had epilepsy, parental overprotection, and parents' tendency to impose greater restrictions on the child with epilepsy than on siblings without epilepsy. Future research investigating the communication strategies of families living with epilepsy is needed in order to create effective communication-based interventions for discussing epilepsy within the home.
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Affiliation(s)
- S O'Toole
- School of Nursing and Human Sciences, Faculty of Science and Health, Dublin City University, Dublin 9, Ireland
| | - A Benson
- School of Nursing and Human Sciences, Faculty of Science and Health, Dublin City University, Dublin 9, Ireland
| | - V Lambert
- School of Nursing and Human Sciences, Faculty of Science and Health, Dublin City University, Dublin 9, Ireland.
| | - P Gallagher
- School of Nursing and Human Sciences, Faculty of Science and Health, Dublin City University, Dublin 9, Ireland
| | - A Shahwan
- Neurology Department, Temple Street Children's University Hospital, Temple Street, Dublin 1, Ireland
| | - J K Austin
- Professor Emerita, Indiana University School of Nursing, Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
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18
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Leyenaar JK, Bergert L, Mallory LA, Engel R, Rassbach C, Shen M, Woehrlen T, Cooperberg D, Coghlin D. Pediatric primary care providers' perspectives regarding hospital discharge communication: a mixed methods analysis. Acad Pediatr 2015; 15:61-8. [PMID: 25444655 PMCID: PMC4371737 DOI: 10.1016/j.acap.2014.07.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2013] [Revised: 07/18/2014] [Accepted: 07/19/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Effective communication between inpatient and outpatient providers may mitigate risks of adverse events associated with hospital discharge. However, there is an absence of pediatric literature defining effective discharge communication strategies at both freestanding children's hospitals and general hospitals. The objectives of this study were to assess associations between pediatric primary care providers' (PCPs) reported receipt of discharge communication and referral hospital type, and to describe PCPs' perspectives regarding effective discharge communication and areas for improvement. METHODS We administered a questionnaire to PCPs referring to 16 pediatric hospital medicine programs nationally. Multivariable models were developed to assess associations between referral hospital type and receipt and completeness of discharge communication. Open-ended questions asked respondents to describe effective strategies and areas requiring improvement regarding discharge communication. Conventional qualitative content analysis was performed to identify emergent themes. RESULTS Responses were received from 201 PCPs, for a response rate of 63%. Although there were no differences between referral hospital type and PCP-reported receipt of discharge communication (relative risk 1.61, 95% confidence interval 0.97-2.67), PCPs referring to general hospitals more frequently reported completeness of discharge communication relative to those referring to freestanding children's hospitals (relative risk 1.78, 95% confidence interval 1.26-2.51). Analysis of free text responses yielded 4 major themes: 1) structured discharge communication, 2) direct personal communication, 3) reliability and timeliness of communication, and 4) communication for effective postdischarge care. CONCLUSIONS This study highlights potential differences in the experiences of PCPs referring to general hospitals and freestanding children's hospitals, and presents valuable contextual data for future quality improvement initiatives.
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Affiliation(s)
- JoAnna K. Leyenaar
- Division of Pediatric Hospital Medicine, Department of Pediatrics, Tufts University School of Medicine, Boston, MA
| | - Lora Bergert
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The John A Burns School of Medicine, Honolulu, HI
| | - Leah A. Mallory
- Division of Pediatric Hospital Medicine, Department of Pediatrics, The Barbara Bush Children’s Hospital at Maine Medical Center, Portland, ME
| | - Richard Engel
- University of Arizona College of Medicine-Phoenix, Phoenix Children’s Hospital, Phoenix, AZ
| | - Caroline Rassbach
- Stanford University School of Medicine, Lucile Packard Children’s Hospital, Palo Alto, CA 94304
| | - Mark Shen
- Dell Children’s Medical Center of Central Texas
| | - Tess Woehrlen
- Michigan State University College of Osteopathic Medicine, East Lansing MI
| | - David Cooperberg
- Drexel University College of Medicine, St. Christopher’s Hospital for Children, Philadelphia, PA
| | - Daniel Coghlin
- The Warren Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, RI
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Hamburger EK, Lane JL, Agrawal D, Boogaard C, Hanson JL, Weisz J, Ottolini M. The referral and consultation entrustable professional activity: defining the components in order to develop a curriculum for pediatric residents. Acad Pediatr 2015; 15:5-8. [PMID: 25528123 DOI: 10.1016/j.acap.2014.10.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 10/30/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Ellen K Hamburger
- Department of Pediatrics, George Washington University, Children's National Health System, Office of Medical Education, Washington, DC.
| | - J Lindsey Lane
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colo
| | - Dewesh Agrawal
- Department of Pediatrics, George Washington University, Children's National Health System, Office of Medical Education, Washington, DC
| | - Claire Boogaard
- Department of Pediatrics, George Washington University, Children's National Health System, Office of Medical Education, Washington, DC
| | - Janice L Hanson
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colo; Department of Family Medicine, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colo
| | - Jessica Weisz
- Department of Pediatrics, George Washington University, Children's National Health System, Office of Medical Education, Washington, DC
| | - Mary Ottolini
- Department of Pediatrics, George Washington University, Children's National Health System, Office of Medical Education, Washington, DC
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Stille CJ, Fischer SH, La Pelle N, Dworetzky B, Mazor KM, Cooley WC. Parent partnerships in communication and decision making about subspecialty referrals for children with special needs. Acad Pediatr 2013; 13:122-32. [PMID: 23356961 DOI: 10.1016/j.acap.2012.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 12/03/2012] [Accepted: 12/07/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To describe factors that influence parent-clinician partnerships in information exchange and shared decision making (SDM) when children with special health care needs are referred to subspecialists. METHODS We conducted focus groups with parents of children with special health care needs and pediatric primary care and subspecialty clinicians about how to include parents as partners in information exchange and SDM. Five parent and 5 clinician groups were held to identify themes to inform the development of interventions to promote parent partnerships; evaluate a prototype referral care plan and related parent supports as one example of a partnership tool; and compare the views of parents and clinicians. We used investigator triangulation and member checking to improve validity. RESULTS Nineteen parents and 23 clinicians participated. Parents discussed partnerships more easily than clinicians did, though clinicians offered more ideas as sessions progressed. Parents and clinicians agreed on the importance of 3-way communication and valued primary care involvement in all stages of referral and consultation. SDM was seen by all as important; clinicians cited difficulties inherent in discussing unclear options, while parents cited insufficient information as a barrier to understanding. Use of a brief referral care plan, with parent coaching, was embraced by all parents and most clinicians. Clinicians cited time pressures and interference with work flow as potential barriers to its use. CONCLUSIONS Parents and clinicians endorse partnership in referrals, though relatively greater enthusiasm from parents may signal the need for work in implementing this partnership. Use of a care plan to support parent engagement appears promising as a partnership tool.
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Affiliation(s)
- Christopher J Stille
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
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Adams S, Cohen E, Mahant S, Friedman JN, MacCulloch R, Nicholas DB. Exploring the usefulness of comprehensive care plans for children with medical complexity (CMC): a qualitative study. BMC Pediatr 2013; 13:10. [PMID: 23331710 PMCID: PMC3570291 DOI: 10.1186/1471-2431-13-10] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Accepted: 01/04/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Medical Home model recommends that Children with Special Health Care Needs (CSHCN) receive a medical care plan, outlining the child's major medical issues and care needs to assist with care coordination. While care plans are a primary component of effective care coordination, the creation and maintenance of care plans is time, labor, and cost intensive, and the desired content of the care plan has not been studied. The purpose of this qualitative study was to understand the usefulness and desired content of comprehensive care plans by exploring the perceptions of parents and health care providers (HCPs) of children with medical complexity (CMC). METHODS This qualitative study utilized in-depth semi-structured interviews and focus groups. HCPs (n = 15) and parents (n = 15) of CMC who had all used a comprehensive care plan were recruited from a tertiary pediatric academic health sciences center. Themes were identified through grounded theory analysis of interview and focus group data. RESULTS A multi-dimensional model of perceived care plan usefulness emerged. The model highlights three integral aspects of the care plan: care plan characteristics, activating factors and perceived outcomes of using a care plan. Care plans were perceived as a useful tool that centralized and focused the care of the child. Care plans were reported to flatten the hierarchical relationship between HCPs and parents, resulting in enhanced reciprocal information exchange and strengthened relationships. Participants expressed that a standardized template that is family-centered and includes content relevant to both the medical and social needs of the child is beneficial when integrated into overall care planning and delivery for CMC. CONCLUSIONS Care plans are perceived to be a useful tool to both health care providers and parents of CMC. These findings inform the utility and development of a comprehensive care plan template as well as a model of how and when to best utilize care plans within family-centered models of care.
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Affiliation(s)
- Sherri Adams
- Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, Ontario, M5T 1P8, Canada
| | - Eyal Cohen
- Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, 1 King’s College Circle, Toronto, Ontario, M5S 1A8, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Suite 425, Toronto, Ontario, M5T 3M6, Canada
- CanChild Center for Childhood Disability Research, 1400 Main Street West, Room 408, Hamilton, Ontario, L8S 1C7, Canada
| | - Sanjay Mahant
- Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, 1 King’s College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Jeremy N Friedman
- Division of Paediatric Medicine, The Hospital for Sick Children, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
- Department of Paediatrics, University of Toronto, 1 King’s College Circle, Toronto, Ontario, M5S 1A8, Canada
| | - Radha MacCulloch
- School of Social Work, McGill, University of Montreal, 3506 University Street, Montreal, Quebec, H3A 2A7, Canada
| | - David B Nicholas
- Faculty of Social Work, University of Calgary, 2500 University Drive NW, Calgary, Alberta, T2N 1N4, Canada
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22
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Golden SL, Nageswaran S. Caregiver voices: coordinating care for children with complex chronic conditions. Clin Pediatr (Phila) 2012; 51:723-9. [PMID: 22563062 DOI: 10.1177/0009922812445920] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children with complex chronic conditions (CCC) receive care from multiple providers and agencies for a prolonged period of time. Coordination of care between providers is essential in the care of children with CCC. The purpose of this study was to determine which aspects of care coordination are important to caregivers and explore the challenges faced by caregivers in coordinating care. Using focus group methodology, the authors elicited experiences of caregivers relative to care coordination for children with CCC. Several themes emerged: (a) more information sharing and quality communication is needed among all those involved in providing care for children with CCC, (b) caregivers need help in navigating the system of care, and (c) caregivers develop strategies to cope with care coordination demands. Caregiver burden of coordinating care for children with CCC can be alleviated in part through improved communication and collaboration between agencies and providers and through developing easier ways to navigate a complex health system.
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Nageswaran S, Ip EH, Golden SL, O’Shea TM, Easterling D. Inter-agency collaboration in the care of children with complex chronic conditions. Acad Pediatr 2012; 12:189-97. [PMID: 22583632 PMCID: PMC3354334 DOI: 10.1016/j.acap.2012.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 02/21/2012] [Accepted: 02/22/2012] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The purpose of this article was to describe the network of collaboration among agencies that serve children with complex chronic conditions (CCCs) and identify gaps in the network. METHODS We surveyed representatives from agencies that serve children with CCCs in Forsyth County, North Carolina, about their agencies' existing and desired collaborations with other agencies in the network. We used Social Network Analytical (SNA) methods to describe gaps in the network. Mean out-degree and in-degree centrality (number of collaborative ties extending from or directed toward an agency) and density (ratio of extant ties to all possible ties) were measured. RESULTS In this network with 3658 possible collaborative ties, care-coordination agencies and pediatric practices reported the highest existing collaborations with other agencies (out-degree centrality: 32 and 30, respectively). Pediatric practices reported strong ties with subspecialty clinics (density: 73%), but weak ties with family support services (density: 3%). Pediatric practices and subspecialty clinics (in-degree: 26) received the highest collaborative ties from other agencies. Support services and durable medical equipment (DME) companies reported low ties with other agencies (out-degree: 7 and 10, respectively). Nursing agencies reported the highest desired collaborations (out-degree: 18). Support services, pediatric practices, and care-coordination programs had the highest in-degree centrality (7, 6, and 6, respectively) for desired collaborations. Nursing agencies and support services had the greatest gaps in collaboration. CONCLUSION Although collaboration exists among agencies serving children with CCCs, there are many gaps in the network. Future studies should explore barriers and facilitators to inter-agency collaborations and whether increased collaboration in the network improves patient-level outcomes.
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Affiliation(s)
- Savithri Nageswaran
- Department of Pediatrics, 1 Medical Center Blvd, Winston-Salem, NC 27157, USA.
| | - Edward H. Ip
- Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC,Biostatistical Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Shannon L. Golden
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC
| | - T. Michael O’Shea
- Department of Pediatrics, Wake Forest School of Medicine, Winston-Salem, NC,Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC
| | - Douglas Easterling
- Social Sciences & Health Policy, Wake Forest School of Medicine, Winston-Salem, NC
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Gulmans J, Vollenbroek-Hutten M, van Gemert-Pijnen L, van Harten W. A web-based communication system for integrated care in cerebral palsy: experienced contribution to parent-professional communication. Int J Integr Care 2012; 12:e9. [PMID: 22977435 PMCID: PMC3429144 DOI: 10.5334/ijic.672] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 12/14/2011] [Accepted: 01/20/2012] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION To improve communication in the integrated care setting of children with cerebral palsy, we developed a web-based system for parent-professional and inter-professional communication. The present study aimed to evaluate parents' experiences regarding the system's contribution to their communication with professionals during a six-months pilot in three Dutch care regions. In addition, factors associated with parents' system use and non-use were analyzed. THEORY AND METHODS The system's functional specifications were based on key elements of the Chronic Care Model and quality dimensions formulated by the Institute of Medicine. At baseline, parents completed a T0-questionnaire on their experiences regarding sufficiency of contact, accessibility of professionals, timeliness of information exchange, consistency of information and parents' role as messenger of information and/or care coordinator. After the pilot, parents completed a T1-questionnaire on their experiences regarding the system's contribution to each of these aspects. RESULTS Of the 30 participating parents 21 had used the system, of which 20 completed the T1-questionnaire. All these parents indicated that they had experienced a contribution of the system to parent-professional communication, especially with respect to accessibility of professionals, sufficiency of contact and timeliness of information exchange, and to a lesser extent consistency of information and parents' messenger/coordinator role. In comparison with non-users, users had less positive baseline experiences with accessibility and a higher number of professionals in the child's care network. CONCLUSIONS All users indicated a contribution of the system to parent-professional communication, although the extent of the experienced contribution varied considerably. Based on the differences found between users and non-users, further research might focus on the system's value for complex care networks and problematic access to professionals.
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Affiliation(s)
- Jitske Gulmans
- Roessingh Research and Development, Institute for Research in Rehabilitation Medicine and Technology, Enschede, The Netherlands
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Gulmans J, Vollenbroek-Hutten MM, van Gemert-Pijnen LJ, van Harten WH. Determinants of use and non-use of a web-based communication system in cerebral palsy care: evaluating the association between professionals' system use and their a priori expectancies and background. BMC Med Inform Decis Mak 2011; 11:43. [PMID: 21682911 PMCID: PMC3150243 DOI: 10.1186/1472-6947-11-43] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2010] [Accepted: 06/18/2011] [Indexed: 12/31/2022] Open
Abstract
Background Previously we described parents' and professionals' experiences with a web-based communication system in a 6-month pilot in three Dutch cerebral palsy care settings. We found that half of the participating professionals had not used the system, and of those who had used the system one third had used it only once. The present study aimed to evaluate whether professionals' system use was associated with their a priori expectancies and background. Methods Professionals who had not used the system (n = 54) were compared with professionals who had used the system more than once (n = 46) on the basis of their questionnaire responses before the pilot, their affiliation and the number of patients which they represented in the study. The questionnaire items comprised professionals' expectancies regarding the system's performance and ease of use, as well as the expected time availability and integration into daily care practice. Results Overall, users had higher a priori expectancies than non-users. System use was associated with expected ease of use (p = .046) and time availability (p = .005): 50% of the users (vs. 31% of the non-users) expected that the system would be easy to use and 93% of the users (vs. 72% of the non-users) expected that they would be able to reserve a time slot each week for responding to submitted questions. With respect to professionals' affiliation, system use was associated with professionals' institution (p = .003) and discipline (p = .001), with more (para-) medical professionals among users (93% vs. 63% among non-users), and more education professionals among non-users (37% vs. 7% among users). In addition, users represented more patients (mean 2, range 1-8) than non-users (mean 1.1, range 1-2) (p = .000). Conclusions Professionals' system use was associated with expected ease of use and time availability, professionals' affiliation and the number of represented patients, while no association was found with expected performance of the system. To achieve higher adoption rates in the future, it is important to further develop the technology by optimizing the system's ease of use and interoperability and including advanced consultation options. In addition, better identified end users should be more extensively informed about the system's possibilities through tailored education.
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Affiliation(s)
- Jitske Gulmans
- Roessingh Research & Development, Research Institute for Rehabilitation and Technology, PO Box 310, 7500 AH Enschede, The Netherlands.
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Ghosh S, Rezazadeh SM. Consultation With Pediatricians in the Management of Attention-Deficit/Hyperactivity Disorder. JOURNAL OF EDUCATIONAL AND PSYCHOLOGICAL CONSULTATION 2011. [DOI: 10.1080/10474412.2011.571477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Abstract
CONTEXT In the United States, more than a third of patients are referred to a specialist each year, and specialist visits constitute more than half of outpatient visits. Despite the frequency of referrals and the importance of the specialty-referral process, the process itself has been a long-standing source of frustration among both primary care physicians (PCPs) and specialists. These frustrations, along with a desire to lower costs, have led to numerous strategies to improve the specialty-referral process, such as using gatekeepers and referral guidelines. METHODS This article reviews the literature on the specialty-referral process in order to better understand what is known about current problems with the referral process and what solutions have been proposed. The article first provides a conceptual framework and then reviews prior literature on the referral decision, care coordination including information transfer, and access to specialty care. FINDINGS PCPs vary in their threshold for referring a patient, which results in both the underuse and the overuse of specialists. Many referrals do not include a transfer of information, either to or from the specialist; and when they do, it often contains insufficient data for medical decision making. Care across the primary-specialty interface is poorly integrated; PCPs often do not know whether a patient actually went to the specialist, or what the specialist recommended. PCPs and specialists also frequently disagree on the specialist's role during the referral episode (e.g., single consultation or continuing co-management). CONCLUSIONS There are breakdowns and inefficiencies in all components of the specialty-referral process. Despite many promising mechanisms to improve the referral process, rigorous evaluations of these improvements are needed.
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Affiliation(s)
- Ateev Mehrotra
- University of Pittsburgh School of Medicine, 230 McKee Place, Suite 600, Pittsburgh, PA 15213, USA.
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Ross WJ, Chan E, Harris SK, Goldman SJ, Rappaport LA. Pediatrician-psychiatrist collaboration to care for children with attention deficit hyperactivity disorder, depression, and anxiety. Clin Pediatr (Phila) 2011; 50:37-43. [PMID: 20724316 DOI: 10.1177/0009922810379499] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To describe pediatrician experiences collaborating with psychiatrists when caring for children with attention deficit hyperactivity disorder (ADHD), depression, and anxiety. METHOD A random sample of Massachusetts primary care pediatricians completed a mailed self-report survey. RESULTS Response rate was 50% (100/198). Most pediatricians preferred psychiatrists to initiate medications for anxiety (87%) or depression (85%), but not ADHD (22%). Only 14% of respondents usually received information about a psychiatry consultation. For most (88%), the family was the primary conduit of information from psychiatrists, although few (14%) believed the family to be a dependable informant. Despite this lack of direct communication, most pediatricians reported refilling psychiatry-initiated prescriptions for ADHD (88%), depression (76%), and anxiety (72%). CONCLUSIONS Pediatricians preferred closer collaboration with psychiatrists for managing children with anxiety and depression, but not ADHD. The communication gap between psychiatrists and pediatricians raises concerns about quality of care for children with psychiatric conditions.
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Affiliation(s)
- Wendy J Ross
- Children's Hospital Boston, Boston, MA 02115, USA
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Aruda MM, Kelly M, Newinsky K. Unmet Needs of Children With Special Health Care Needs in a Specialized Day School Setting. J Sch Nurs 2010; 27:209-18. [DOI: 10.1177/1059840510391670] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Children with Special Health Care Needs (CSHCN) represent a significant component of the pediatric population. They often present to schools with multiple and increasingly complex health issues, including medical technology dependency. Their daily variation in health status requires close monitoring and communication among caregivers. Limited research exists regarding parental concerns and communication between health providers, schools, and families. This study identifies the concerns of parents with CSHCN families, including satisfaction with communication between medical providers and schools. Parents completed a survey adapted from the American Academy of Pediatrics (AAP). Analysis of data indicated a high utilization of primary care services but highlighted persistent difficulty accessing services. This study demonstrates families have basic unmet needs in attaining services, including respite and palliative care; indicated an interest in improved communication and coordination of health information between schools and their primary health care providers; and expressed interest in augmenting school health services.
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Tom JO, Tseng CW, Davis J, Solomon C, Zhou C, Mangione-Smith R. Missed well-child care visits, low continuity of care, and risk of ambulatory care-sensitive hospitalizations in young children. ARCHIVES OF PEDIATRICS & ADOLESCENT MEDICINE 2010; 164:1052-8. [PMID: 21041598 PMCID: PMC3551592 DOI: 10.1001/archpediatrics.2010.201] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES To determine if adherence to the recommended well-child care (WCC) visit schedule, independent of continuity of care (COC), is associated with lower risk of ambulatory care-sensitive hospitalizations (ACSH) and whether this association varies by chronic disease status. DESIGN Population-based, retrospective cohort study. SETTING Hawaii's largest health plan from 1999 to 2006. PARTICIPANTS A total of 36 944 children aged 3.5 years or younger were eligible if they were enrolled prior to 2 months of age, had 4 or more outpatient visits during the study period, and had an enrollment period that overlapped with 1 or more WCC visit interval. MAIN EXPOSURE Patients' WCC visit adherence and COC index. MAIN OUTCOME MEASURE Risk of ACSH (hazard ratio [HR]). RESULTS Overall, 8921 (24%) children had 1 or more chronic disease. The proportion of ACSH among healthy children vs those with 1 or more chronic disease were 3% (n = 751) and 7% (n = 645), respectively. For children with chronic disease, those with the lowest WCC visit adherence (0%-25%) had 1.9 times (HR, 1.9; 95% confidence interval [CI], 1.5-2.5) the risk of ACSH compared with those in the highest category (75%-100%). The risk of ACSH for children with chronic disease who fell into the lowest COC category (0-0.25) was 2.4 times (HR, 2.4; 95% CI, 1.7-3.5) higher than for those who fell into the highest category (0.75-1.0). CONCLUSIONS For children with chronic disease, both low WCC visit adherence and COC are independently associated with an increased risk of ACSH. Providing access to a consistent source of primary care appears to be important to this vulnerable population.
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Affiliation(s)
- Jeffrey O Tom
- Kaiser Center for Health Research-Hawaii, 501 Alakawa Street, Honolulu, HI 96817, USA.
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Gulmans J, Vollenbroek-Hutten MMR, Visser JJW, Nijeweme-d'Hollosy WO, van Gemert-Pijnen JEWCL, van Harten WH. A web-based communication system for integrated care in cerebral palsy: design features, technical feasibility and usability. J Telemed Telecare 2010; 16:389-93. [PMID: 20736247 DOI: 10.1258/jtt.2010.091013] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We developed a secure, web-based system for parent-professional and inter-professional communication. The aim was to improve communication in the care of children with cerebral palsy. We conducted a six-month trial of the system in three Dutch health-care regions. The participants were the parents of 30 cerebral palsy patients and 120 professional staff involved in their care. Information about system usage was extracted from the system's database. The experience of the parents and professionals was evaluated by a questionnaire after six months. The system proved to be technically robust and reliable. A total of 21 parents (70%) and 66 professionals (55%) used the system. The parents submitted 111 questions and 59 responses, with a mean of 5 questions (range 1-17) and 3 responses (range 1-9) per parent. The professionals submitted 79 questions and 237 responses, with a mean of 2 questions (range 1-8) and 4 responses (range 1-23) per professional. Most parents (95%) and some professionals (30%) reported value in using the system, which ranged from efficiency and accessibility to flexibility and transparency. The web-based communication system was technically feasible and produced improved parent-professional and inter-professional communication. It may be especially valuable if frequent interventions or consultations about a child's care are required, involving complex care networks of different professionals and organisations.
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Affiliation(s)
- Jitske Gulmans
- Roessingh Research and Development, Institute for Research in Rehabilitation Medicine and Technology, Enschede, The Netherlands.
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Stille CJ. Communication, comanagement, and collaborative care for children and youth with special healthcare needs. Pediatr Ann 2009; 38:498-504. [PMID: 19772236 DOI: 10.3928/00904481-20090820-09] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Christopher J Stille
- Department of Pediatrics, University of Massachusetts Medical School, Benedict A3-125, 55 Lake Avenue North, Worchester, Massachusetts 01655, USA.
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Stille CJ, Frantz J, Vogel LC, Lighter D. Building communication between professionals at children's specialty hospitals and the medical home. Clin Pediatr (Phila) 2009; 48:661-73. [PMID: 19286621 DOI: 10.1177/0009922809332590] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Build a quality improvement (QI) intervention to improve communication between a children's specialty hospital and referring primary care providers (PCPs). METHODS A network of charitable children's hospitals identified improving communication as a systemwide goal. At one model hospital, we used qualitative telephone interviewing of hospital specialists and staff, and referring PCPs, to characterize the communication system and identify potential improvements. We identified potential high-impact areas through content analysis and developed a QI change package with hospital leadership. RESULTS Participants described inconsistent communication, with no systematic identification of PCPs. Families were the typical means of inter-physician communication. Multiple non-PCP referral sources were a major contributor to communication breakdowns. Respondents identified a system for identification and communication with PCPs as an essential first step. CONCLUSIONS Systems for communication with PCPs are underdeveloped at a children's charitable specialty hospital. Straightforward changes could build an effective system that is generalizable to other hospitals.
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Affiliation(s)
- Christopher J Stille
- Department of Pediatrics, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
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Nelson CS, Tandon SD, Duggan AK, Serwint JR. Communication between key stakeholders within a medical home: a qualitative study. Clin Pediatr (Phila) 2009; 48:252-62. [PMID: 18768937 DOI: 10.1177/0009922808323106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study was to determine perceived benefits, detriments, and barriers to communication between pediatric providers and home visitors. The authors performed a cross-sectional, qualitative study consisting of 3 focus groups with paraprofessional home visitors (n=12), 6 with parents receiving home visiting (n=33), and 4 with pediatric providers whose patients received home visiting (n=19). Emerging themes were generated by an inductive analytic approach. Perceived benefits included home visitors assisting parents with communication, giving providers family information, and reinforcing providers' guidance. Detriments included parental concern of sharing confidential information and providers becoming aware of family issues for which they are unprepared to act. Barriers included parental consent, logistics of home visitor-provider communication, and providers' lack of knowledge about home visitor programs/roles. Greater coordination between home visitation programs and pediatric providers may strengthen home visiting services and reinforce advice and anticipatory guidance given by providers.
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Affiliation(s)
- Catherine S Nelson
- Department of Pediatrics, Division of General Pediatrics & Adolescent Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
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