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Cassidy L, Quirke MB, Alexander D, Greene J, Hill K, Connolly M, Brenner M. Integrated care for children living with complex care needs: an evolutionary concept analysis. Eur J Pediatr 2023; 182:1517-1532. [PMID: 36780041 PMCID: PMC9924191 DOI: 10.1007/s00431-023-04851-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 02/14/2023]
Abstract
Children with complex care needs (CCNs) are in need of improved access to healthcare services, communication, and support from healthcare professionals to ensure high-quality care is delivered to meet their needs. Integrated care is viewed as a key component of care delivery for children with CCNs, as it promotes the integration of healthcare systems to provide family and child-centred care across the entire health spectrum. There are many definitions and frameworks that support integrated care, but there is a lack of conceptual clarity around the term. Furthermore, it is often unclear how integrated care can be delivered to children with CCNs, therefore reinforcing the need for further clarification on how to define integrated care. An evolutionary concept analysis was conducted to clarify how integrated care for children with CCNs is defined within current literature. We found that integrated care for children with CCNs refers to highly specialised individualised care within or across services, that is co-produced by interdisciplinary teams, families, and children, supported by digital health technologies. Conclusion: Given the variation in terms of study design, outcomes, and patient populations this paper highlights the need for further research into methods to measure integrated care. What is Known: • Children with complex care needs require long-term care, and are in need of improved services, communication, and information from healthcare professionals to provide them with the ongoing support they need to manage their condition. • Integrated care is a key component in healthcare delivery for children with complex care needs as it has the potential to improve access to family-centred care across the entire health spectrum. What is New: • Integrated care for children with CCNs refers to highly specialised individualised care within or across services, that is co-produced by interdisciplinary teams, families, and children, supported by digital health technologies. • There is a need for the development of measurement tools to effectively assess integrated care within practice.
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Affiliation(s)
- Lorna Cassidy
- School of Nursing, Midwifery and Health Systems, University College Dublin, Health Sciences Building, Belfield, Dublin 4 Ireland
| | - Mary Brigid Quirke
- School of Nursing, Midwifery and Health Systems, University College Dublin, Health Sciences Building, Belfield, Dublin 4 Ireland
| | - Denise Alexander
- School of Nursing, Midwifery and Health Systems, University College Dublin, Health Sciences Building, Belfield, Dublin 4 Ireland
| | - Jo Greene
- School of Nursing, Midwifery and Health Systems, University College Dublin, Health Sciences Building, Belfield, Dublin 4 Ireland
| | - Katie Hill
- School of Nursing, Midwifery and Health Systems, University College Dublin, Health Sciences Building, Belfield, Dublin 4 Ireland
| | - Michael Connolly
- School of Nursing, Midwifery and Health Systems, University College Dublin, Health Sciences Building, Belfield, Dublin 4 Ireland
| | - Maria Brenner
- School of Nursing, Midwifery and Health Systems, University College Dublin, Health Sciences Building, Belfield, Dublin 4 Ireland
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Perez JM, Melvin PR, Berry JG, Mullen MP, Graham RJ. Outcomes for Children With Pulmonary Hypertension Undergoing Tracheostomy Placement: A Multi-Institutional Analysis. Pediatr Crit Care Med 2022; 23:717-726. [PMID: 35687103 DOI: 10.1097/pcc.0000000000003002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe epidemiology, interventions, outcomes, and the health services experience for a cohort of children with pulmonary hypertension (PH) who underwent tracheostomy placement and to identify risk factors for inhospital mortality and 30-day readmissions. DESIGN Retrospective cohort study of the Pediatric Health Information System database. SETTING Thirty-seven freestanding U.S. children's hospitals. PATIENTS Patients 31 days to 21 years old who were discharged from the hospital between January 1, 2009, and December 31, 2017, with a diagnosis of primary or secondary PH, and who underwent tracheostomy placement. Outcomes were examined over a 2-year period from the time of discharge from the index encounter. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 793 patients with PH who underwent tracheostomy placement. The overall inhospital mortality rate was 23.7%. Secondary PH due to congenital heart disease (CHD) was significantly associated with overall inhospital mortality (adjusted odds ratio [OR], 2.36; 95% CI, 1.38-4.04). The rate of 30-day readmissions for patients over the 2-year follow-up period was 33.3%. Tracheostomy during the index encounter and the diagnosis of secondary PH due to CHD were significantly associated with lower rates of 30-day readmissions (adjusted OR, 0.34; 95% CI, 0.19-0.61; and adjusted OR, 0.43; 95% CI, 0.24-0.77, respectively). CONCLUSIONS In the context of expanding utilization of tracheostomy and long-term ventilation, children with PH are among the highest risk cohorts for extended and repeated hospitalization and death. Tracheostomy placement during the index encounter was associated with fewer 30-day readmissions over the 2-year follow-up period. Further understanding of which subgroups may benefit from earlier intervention and which subgroups are at highest risk may offer important clinical insight when considering optimal timing of tracheostomy and may enhance informed decision-making for all stakeholders.
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Affiliation(s)
- Jennifer M Perez
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Patrice R Melvin
- Office of Health Equity and Inclusion, Boston Children's Hospital, Boston, MA
| | - Jay G Berry
- Complex Care Service, Division of General Pediatrics, Boston Children's Hospital, Boston, MA
| | - Mary P Mullen
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Robert J Graham
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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Bird M, Carter N, Lim A, Kazmie N, Fajardo C, Reaume S, McGillion MH. A Novel Hospital-to-Home System for Children With Medical Complexities: Usability Testing Study. JMIR Form Res 2022; 6:e34572. [PMID: 35969456 PMCID: PMC9419046 DOI: 10.2196/34572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/13/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background Children with medical complexity (CMC) are a group of young people who have severe complex chronic conditions, substantial family-identified service needs, functional limitations, and high health care resource use. Technology-enabled hospital-to-home interventions designed to deliver comprehensive care in the home setting are needed to ease CMC family stress, provide proactive and comprehensive care to this fragile population, and avoid hospital admissions, where possible. Objective In this usability testing study, we aimed to assess areas of strength and opportunity within the DigiComp Kids system, a hospital-to-home intervention for CMC and their families and care providers. Methods Hospital-based clinicians, family members of medically complex children, and home-based clinicians participated in DigiComp Kids usability testing. Participants were recorded and tasked to think aloud while completing usability testing tasks. Participants were scored on the metrics of effectiveness, efficiency, and satisfaction, and the total usability score was calculated using the Single Usability Metric. Participants also provided insights into user experiences during the postusability testing interviews. Results A total of 15 participants (5 hospital-based clinicians, 6 family members, and 4 home-based clinicians) participated in DigiComp Kids usability testing. The participants were able to complete all assigned tasks independently. Error-free rates for tasks ranged from 58% to 100%; the average satisfaction rating across groups was ≥80%, as measured by the Single Ease Question. Task times of participants were variable compared with the task times of an expert DigiComp Kids user. Single Usability Metric scores ranged from 80.5% to 89.5%. In qualitative interviews, participants stressed the need to find the right fit between user needs and the effort required to use the system. Interviews also revealed that the value of the DigiComp Kids system was in its ability to create a digital bridge between hospital and home, enabling participants to foster and maintain connections across boundaries. Conclusions Usability testing revealed strong scores across the groups. Insights gained include the importance of tailoring the implementation of the system to match individual user needs, streamlining key system features, and consideration of the meaning attached to system use by participants to allow for insight into system adoption and sustainment.
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Affiliation(s)
- Marissa Bird
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Nancy Carter
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Audrey Lim
- Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Nadia Kazmie
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | | | - Shannon Reaume
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Michael H McGillion
- School of Nursing, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton, ON, Canada
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Breneol S, Doucet S, McIsaac JL, Riveroll A, Cassidy C, Charlton P, McCulloch H, McKibbon S, Luke A, Splane J, Curran JA. Programmes to support transitions in community care for children with complex care needs: a scoping review. BMJ Open 2022; 12:e056799. [PMID: 35803631 PMCID: PMC9272111 DOI: 10.1136/bmjopen-2021-056799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVE This scoping review aimed to map the range of programmes in the literature to support children and youth with complex care needs and their families during transitions in care in the community. DESIGN A scoping review of the literature. CONTEXT This review included programmes that supported the transition in care to home and between settings in the community. DATA SOURCES We implemented our strategy to search five databases: (1) PubMed; (2) CINAHL; (3) ERIC; (4) PyscINFO and (5) Social Work Abstracts. The search was last implemented on 29 April 2021. STUDY SELECTION Our search results were imported into Covidence Systematic Review Software. First, two reviewers assessed titles and abstracts against our eligibility criteria. Relevant articles were then retrieved in full and reviewed by two reviewers for inclusion. Disagreements were resolved by a third reviewer. DATA EXTRACTION Relevant data were extracted related to population, concept, context, methods and key findings pertinent to our review objective. RESULTS A total of 2482 records were identified. After our two-stage screening process, a total of 27 articles were included for analysis. Articles ranged in the type of transitions being supported and target population. The most common transition reported was the hospital-to-home transition. Intervention components primarily consisted of care coordination using a teams-based approach. The most reported barriers and enablers to implementing these transition care programmes were related to physical opportunities. LIMITATIONS Included articles were limited to English and French. CONCLUSIONS This review identified important gaps within the literature, as well as areas for future consideration to ensure the effective development and implementation of programmes to support children and youth with complex care needs during transitions in care.
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Affiliation(s)
- Sydney Breneol
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- Strengthening Transitions in Care Lab, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Shelley Doucet
- Centre for Research in Integrated Care, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Jessie-Lee McIsaac
- Faculty of Education and Department of Child and Youth Study, Mount Saint Vincent University, Halifax, Nova Scotia, Canada
| | - Angela Riveroll
- Department of Applied Human Sciences, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Christine Cassidy
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Patricia Charlton
- Department of Applied Human Sciences, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Holly McCulloch
- Strengthening Transitions in Care Lab, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Shelley McKibbon
- W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Alison Luke
- Centre for Research in Integrated Care, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Jennifer Splane
- Centre for Research in Integrated Care, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Janet A Curran
- School of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- Strengthening Transitions in Care Lab, IWK Health Centre, Halifax, Nova Scotia, Canada
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Davies SC, Lundine JP, Justice AF. Care Coordination for Children with Special Health Care Needs: A Scoping Review to Inform Strategies for Students with Traumatic Brain Injuries. J Sch Health 2022; 92:270-281. [PMID: 34907533 DOI: 10.1111/josh.13132] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/28/2021] [Accepted: 06/29/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Chronic and complex medical issues, including traumatic brain injuries (TBIs), have significant educational implications. The purpose of this study was to identify and summarize the literature on care coordination strategies among health care professionals, educators, and caregivers for children with special health care needs (CSHCN). Clarifying factors that influence care coordination for CSHCN can inform future studies on care coordination for students with TBI. Improved understanding of these factors may lead to better communication, reduction of unmet needs, more efficient service access, and improved long-term outcomes for children. METHODS A scoping review was conducted, guided by PRISMA-ScR methodology. Five databases (CINAHL, PSYCINFO, EMBASE, ERIC, PubMed) were searched to identify relevant studies that focused on care coordination and educational settings. RESULTS Twelve articles met inclusion criteria. Care coordination interventions for CSHCN used in educational settings focused on relationship-building strategies, clear procedures and roles, and education of members of the school community. CONCLUSIONS Findings highlight strategies to coordinate care for CSHCN and factors that may moderate effects of these interventions. Key stakeholders should now study these strategies specifically in children with TBI.
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Affiliation(s)
- Susan C Davies
- Department of Counselor Education and Human Services, University of Dayton, 300 College Park, Dayton, OH, 45469
| | - Jennifer P Lundine
- Department of Speech and Hearing Science, The Ohio State University Division of Clinical Therapies and Inpatient Rehabilitation, Nationwide Children's Hospital 101A Pressey Hall, 1070 Carmack RD, Columbus, OH, 43210
| | - Ann F Justice
- Department of Counselor Education and Human Services University of Dayton 300 College Park, Dayton, OH, 45469
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Palusak C, Shook B, Davies SC, Lundine JP. A scoping review to inform care coordination strategies for youth with traumatic brain injuries: Care coordination personnel. International Journal of Care Coordination 2022. [DOI: 10.1177/20534345211070647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction & Importance: Effective, patient-centered care coordination has been shown to improve outcomes for children with special healthcare needs (CSHCN), who often have complex, long-term involvement with multiple service providers. Traumatic brain injury (TBI) can result in long-term physical, intellectual, social, and emotional disabilities that persist long after acute treatment. Yet, even though it is a chronic condition, TBI remains an area with scarce standardization and research surrounding the complex, long-term care coordination need in this population. The purpose of this scoping review is to summarize current research on outcomes in CSHCN after implementation of care coordinators, whether individual or teams, to inform future research for youth with TBI. Methods: OVID/Medline, CINAHL, PsycINFO, EMBASE, and ERIC databases were searched for articles relevant to care coordination and CSHCN. Results: 31 articles met inclusion criteria. Outcomes for children and families were grouped into 5 major categories: healthcare utilization, cost of care, disease status, parent and child quality of life, and healthcare satisfaction and perception of care. Discussion: Implementation of care coordinators, whether in the form of individuals, dyads, or teams, resulted in overall positive outcomes for CSHCN and their families across all 5 major outcome domains. Future research should be focused on the efficacy of care coordinators differing in profession, qualifications, and educational attainment specifically for the unique needs of children with TBI. Additionally, the application of care coordination within medical homes should be further investigated to increase proactive, preventative care of children with TBI and further reduce reactive, need-based treatment only.
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Affiliation(s)
- Cara Palusak
- Heritage College of Osteopathic Medicine, Ohio University Dublin Campus, Columbus, OH
| | - Brandy Shook
- Department of Speech & Hearing Science, The Ohio State University, Columbus, OH
| | - Susan C. Davies
- Department of Counselor Education and Human Services, University of Dayton, Dayton, OH
| | - Jennifer P. Lundine
- Department of Speech & Hearing Science, The Ohio State University, Columbus, OH
- Division of Clinical Therapies & Inpatient Rehabilitation Program, Nationwide Children's Hospital, Columbus, OH
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Campagna S, Borraccino A, Politano G, Dalmasso M, Ravaglia A, Dimonte V, Gianino MM. Emergency-department accesses in home care paediatric patients: Occurrence and risks of use in a six-year retrospective investigation in Northern Italy. PLoS One 2022; 16:e0262085. [PMID: 34972170 PMCID: PMC8719707 DOI: 10.1371/journal.pone.0262085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 12/18/2021] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the determinants of ED use in paediatric patients enrolled in an Integrated Paediatric Home Care (IPHC) program. Methods A retrospective study was conducted using administrative databases on a cohort of patients enrolled in an IPHC program between January 1st, 2012, and December 31st, 2017, in Northern Italy. ED visits that occurred during the IPHC program were considered. Data were collected considering sociodemographic, clinical and organizational variables. A multivariable stepwise logistic regression analysis was performed. The dependent variable to identify possible associations was ED visit. Results A total of 463 ED visits occurred in 465 children, with an incidence rate of 1. The risk of ED visits significantly increased among children involved in the IPHC program after hospital discharge (OR 1.94). Additionally, the risk of ED visits increased significantly as the duration of IPHC increased (OR 5.80 between 101 and 200 days, to OR 7.84 between 201 and 300 days, OR 12.54 between 301 and 400 days and OR 18.67 to more than 400 days). Conclusion The overall results represent a practical perspective to contribute improving both the service quality of IPHC and reducing low acuity and improper ED use.
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Affiliation(s)
- Sara Campagna
- Department of Public Health and Paediatrics, University of Torino, Torino, Italy
| | - Alberto Borraccino
- Department of Public Health and Paediatrics, University of Torino, Torino, Italy
- * E-mail:
| | - Gianfranco Politano
- Department of Control and Computer Engineering, Politecnico of Torino, Torino, Italy
| | - Marco Dalmasso
- Epidemiology Unit, Local Health Unit TO3, Piedmont Region, Italy
| | - Aldo Ravaglia
- Paediatric General Pratictioner, Local Health Unit TO4, Piedmont Region, Italy
| | - Valerio Dimonte
- Department of Public Health and Paediatrics, University of Torino, Torino, Italy
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Pulcini CD, Belardo Z, Ketterer T, Zorc JJ, Mollen CJ. Improving Emergency Care for Children With Medical Complexity: Parent and Physicians' Perspectives. Acad Pediatr 2021; 21:513-520. [PMID: 32947009 DOI: 10.1016/j.acap.2020.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Children with medical complexity (CMC) have high rates of emergency department (ED) utilization, but little evidence exists on the perceptions of parents and pediatric emergency medicine (PEM) physicians about emergency care. We sought to explore parent and PEM physicians' perspectives about 1) ED care for CMC, and 2) how emergency care can be improved. METHODS We performed semistructured interviews with parents and PEM physicians at a single academic, children's hospital. English-speaking parents were selected utilizing a standard definition of CMC during an ED visit in which their child was admitted to the hospital. All PEM physicians were eligible. We developed separate interview guides utilizing open-ended questions. The trained study team developed and modified a coding tree through an iterative process, double-coded transcripts, monitored inter-rater reliability to ensure adherence, and performed thematic analysis. RESULTS Twenty interviews of parents of CMC and 16 of PEM physicians were necessary for saturation. Parents identified specific challenges related to ED care of their children involving time, information gathering, logistics/convenience, and multifaceted communication between health teams and parents. PEM physicians identified time, data accessibility and availability, and communication as inter-related challenges in caring for CMC in the ED. Suggestions reflected potential solutions to the challenges identified. CONCLUSIONS Time, data, and communication challenges were the main focus for both parents and PEM physicians, and suggestions mirrored these challenges. Further research and quality improvement efforts to better characterize and mitigate the identified challenges could be of value for this vulnerable population.
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Affiliation(s)
- Christian D Pulcini
- Department of Surgery & Pediatrics, University of Vermont Medical Center and Children's Hospital, University of Vermont Larner College of Medicine (CD Pulcini) Burlington, VT.
| | - Zoe Belardo
- University of Pennsylvania (Z Belardo), Philadelphia, Pa
| | - Tara Ketterer
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia (T Ketterer, JJ Zorc, and CJ Mollen), Philadelphia, Pa
| | - Joseph J Zorc
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia (T Ketterer, JJ Zorc, and CJ Mollen), Philadelphia, Pa
| | - Cynthia J Mollen
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Philadelphia (T Ketterer, JJ Zorc, and CJ Mollen), Philadelphia, Pa
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Johnson H, Simons M, Newcomb D, Borkoles E. Understanding Young People and Their Care Providers' Perceptions and Experiences of Integrated Care Within a Tertiary Paediatric Hospital Setting, Using Interpretive Phenomenological Analysis. Int J Integr Care 2020; 20:7. [PMID: 33177966 DOI: 10.5334/ijic.5545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction: Benefits of integrated care include improved health outcomes and more satisfaction with experiences of care for consumers. For children and young people with chronic and complex health conditions, their care may be fragmented due to the multitude of healthcare providers involved. This paper describes the experiences of integrated care in a paediatric tertiary hospital. Theory and methods: Using an Interpretive Phenomenological Analysis approach, semi-structured interviews were conducted with children and young people, their parents and healthcare providers to explore stakeholders’ integrated care experiences. Results: Nineteen interviews were completed (6 children and young people, 7 parents and 6 healthcare providers) and transcribed verbatim. Two recurrent themes were applicable across the three cohorts: ‘agency and empowerment’ and ‘impact of organisational systems, supports and structures’. Discussion and conclusion: Stakeholders’ experiences of integrated care highlighted the need to examine the discrepancies between healthcare strategies, policies and service delivery within a complex, and often inflexible organisational structure. Power imbalance and family agency (including directly with children and young people) needs to be addressed to support the implementation of integrated care.
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Bird M, Li L, Ouellette C, Hopkins K, McGillion MH, Carter N. Use of Synchronous Digital Health Technologies for the Care of Children With Special Health Care Needs and Their Families: Scoping Review. JMIR Pediatr Parent 2019; 2:e15106. [PMID: 31750840 PMCID: PMC6895870 DOI: 10.2196/15106] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/24/2019] [Accepted: 09/19/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Use of synchronous digital health technologies for care delivery to children with special health care needs (having a chronic physical, behavioral, developmental, or emotional condition in combination with high resource use) and their families at home has shown promise for improving outcomes and increasing access to care for this medically fragile and resource-intensive population. However, a comprehensive description of the various models of synchronous home digital health interventions does not exist, nor has the impact of such interventions been summarized to date. OBJECTIVE We aim to describe the various models of synchronous home digital health that have been used in pediatric populations with special health care needs, their outcomes, and implementation barriers. METHODS A systematic scoping review of the literature was conducted, guided by the Arksey and O'Malley Scoping Review Framework. MEDLINE, CINAHL, and EMBASE databases were searched from inception to June 2018, and the reference lists of the included systematic reviews and high-impact journals were hand-searched. RESULTS A total of 38 articles were included in this review. Interventional articles are described as feasibility studies, studies that aim to provide direct care to children with special health care needs, and studies that aim to support family members to deliver care to children with special health care needs. End-user involvement in the design and implementation of studies is evaluated using a human-centered design framework, and factors affecting the implementation of digital health programs are discussed in relation to technological, human, and systems factors. CONCLUSIONS The use of digital health to care for children with special health care needs presents an opportunity to leverage the capacity of technology to connect patients and their families to much-needed care from expert health care providers while avoiding the expenses and potential harms of the hospital-based care system. Strategies to scale and spread pilot studies, such as involving end users in the co-design techniques, are needed to optimize digital health programs for children with special health care needs.
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Affiliation(s)
- Marissa Bird
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Lin Li
- School of Nursing, McMaster University, Hamilton, ON, Canada
- McMaster Children's Hospital, Hamilton, ON, Canada
| | | | | | - Michael H McGillion
- School of Nursing, McMaster University, Hamilton, ON, Canada
- Population Health Research Institute, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Nancy Carter
- School of Nursing, McMaster University, Hamilton, ON, Canada
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Abstract
PURPOSE OF REVIEW Modern medical advances have resulted in an increased survival after extremely preterm birth. However, some infants will develop severe bronchopulmonary dysplasia (BPD) and fail to wean from invasive or noninvasive positive pressure support. It remains unclear which infants will benefit from tracheostomy placement for chronic ventilation. Once the decision to pursue chronic ventilation has been made, questions remain with respect to the timing of tracheotomy surgery, optimal strategies for mechanical ventilation, and multidisciplinary care in both the inpatient and outpatient settings. The appropriate time for weaning mechanical ventilation and tracheostomy decannulation has similarly not been determined. RECENT FINDINGS Although there remains a paucity of randomized controlled trials involving infants with severe BPD, a growing body of evidence suggests that chronic ventilation via tracheostomy is beneficial to support the growth and development of severely affected preterm children. However, delivering such care is not without risk. Chronic ventilation via tracheostomy requires complex care coordination and significant resource utilization. SUMMARY When chronic respiratory insufficiency limits a preterm infant's ability to grow and develop, chronic invasive ventilation may facilitate neurodevelopmental progress and may lead to an improved long-term outcome.
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Foster CC, Agrawal RK, Davis MM. Home Health Care For Children With Medical Complexity: Workforce Gaps, Policy, And Future Directions. Health Aff (Millwood) 2019; 38:987-993. [DOI: 10.1377/hlthaff.2018.05531] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Carolyn C. Foster
- Carolyn C. Foster is an assistant professor of pediatrics in the Division of Academic General Pediatrics and Primary Care at Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, in Chicago, Illinois
| | - Rishi K. Agrawal
- Rishi K. Agrawal is an associate professor of pediatrics in the Division of Hospital-Based Medicine at Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine
| | - Matthew M. Davis
- Matthew M. Davis is a professor and division head of Academic General Pediatrics and Primary Care at Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine
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Graham RJ, Amar-Dolan LR, Roussin CJ, Weinstock PH. Bridging the Stressful Gap Between ICU and Home: Medical Simulation for Pediatric Patients and Their Families. Pediatr Crit Care Med 2019; 20:e221-e224. [PMID: 30664592 DOI: 10.1097/pcc.0000000000001869] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Introduce an expanding role for pediatric critical care and medical simulation to optimize the care for children with technology dependence. DATA SOURCES Limited review of literature and practice for current teaching paradigms, vulnerability of the patient population, and efficacy of simulation as a medical educational tool. CONCLUSIONS In accordance with new care models and patient need, critical care requires parallel evolution of care practices, including new educational and care models, in order to maximally reduce risk, fear, and anxiety and to insure quality and consistent care in the community for patients and families transitioning between the ICU and home environments.
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Affiliation(s)
- Robert J Graham
- Division of Critical Care Medicine Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Laura R Amar-Dolan
- Division of Critical Care Medicine Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
| | - Christopher J Roussin
- Division of Critical Care Medicine Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
| | - Peter H Weinstock
- Division of Critical Care Medicine Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA.,Harvard Medical School, Boston, MA
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Sobotka SA, Gaur DS, Goodman DM, Agrawal RK, Berry JG, Graham RJ. Pediatric patients with home mechanical ventilation: The health services landscape. Pediatr Pulmonol 2019; 54:40-46. [PMID: 30461228 PMCID: PMC7286281 DOI: 10.1002/ppul.24196] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 10/29/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Children with invasive home mechanical ventilation (HMV) are a growing population with complex health service needs. Single institution studies provide insight into successful program structures and outcomes. Our study objectives were to assess health service structures, providers, and programs caring for this population throughout the U.S., and to understand barriers to high-quality care. DESIGN Using purposeful sampling with capture-recapture and snowball sampling methods, we identified key informants for care of the U.S. pediatric HMV population. Informants received web-based surveys with two reminders. Survey domains included respondent characteristics, HMV team composition, and barriers to care. RESULTS Survey response was 71% with 101 completed. Respondents caring for patients in 45 states included physicians (61%), nurses (20%), therapists (12%), case managers (4%), and social workers (2%). Half (53%) of physicians were fellowship trained, most commonly pulmonology (22%) and critical care medicine (13%). The majority (65%) of providers described a dedicated HMV service. The majority (61%) of respondents from a HMV service provided both inpatient and outpatient care. Nearly all respondents (96%) described an inadequate supply of home nurses and 88% reported inadequate respite facilities. CONCLUSIONS Children with HMV assistance receive care from a diverse group of providers with varied team structure. Heterogeneity may reflect patient diversity and provider interest, increasing efficacy but challenging standardization nationwide. Despite team structure variability, similar home care difficulties were universally experienced. Data suggest that the home nursing shortage is a national impediment to quality and efficient discharge with limited community-based support for this vulnerable population.
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Affiliation(s)
- Sarah A Sobotka
- Section of Developmental and Behavioral Pediatrics, The University of Chicago, Chicago, Illinois
| | | | - Denise M Goodman
- Division of Pediatric Critical Care Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rishi K Agrawal
- Division of Hospital-Based Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - Robert J Graham
- Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts
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Graham RJ, McManus ML, Rodday AM, Weidner RA, Parsons SK. Pediatric Specialty Care Model for Management of Chronic Respiratory Failure: Cost and Savings Implications and Misalignment With Payment Models. Pediatr Crit Care Med 2018; 19:412-20. [PMID: 29406371 DOI: 10.1097/PCC.0000000000001472] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe program design, costs, and savings implications of a critical care-based care coordination model for medically complex children with chronic respiratory failure. DESIGN All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data. SETTING Tertiary children's hospital. SUBJECTS Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2-2 million or $407/pt/mo net of program costs. CONCLUSIONS Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established.
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16
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González R, Bustinza A, Fernandez SN, García M, Rodriguez S, García-Teresa MÁ, Gaboli M, García S, Sardón O, García D, Salcedo A, Rodríguez A, Luna MC, Hernández A, González C, Medina A, Pérez E, Callejón A, Toledo JD, Herranz M, López-Herce J. Quality of life in home-ventilated children and their families. Eur J Pediatr 2017; 176:1307-1317. [PMID: 28803432 DOI: 10.1007/s00431-017-2983-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 07/23/2017] [Accepted: 08/03/2017] [Indexed: 11/30/2022]
Abstract
UNLABELLED HMV (home mechanical ventilation) in children has increased over the last years. The aim of the study was to assess perceived quality of life (QOL) of these children and their families as well as the problems they face in their daily life.We performed a multicentric cross-sectional study using a semi-structured interview about the impact of HMV on families and an evaluation questionnaire about perceived QOL by the patient and their families (pediatric quality of life questionnaire (PedsQL4.0)). We studied 41 subjects (mean age 8.2 years). Global scores in PedsQL questionnaire for subjects (median 61.4), and their parents (median 52.2) were below those of healthy children. 24.4% received medical follow-up at home and 71.8% attended school. Mothers were the main caregivers (75.6%), 48.8% of which were fully dedicated to the care of their child. 71.1% consider economic and healthcare resources insufficient. All families were satisfied with the care they provide to their children, even though it was considered emotionally overwhelming (65.9%). Marital conflict and neglect of siblings appeared in 42.1 and 36% of families, respectively. CONCLUSIONS Perceived QOL by children with HMV and their families is lower than that of healthy children. Parents are happy to care for their children at home, even though it negatively affects family life. What is Known: • The use of home mechanical ventilation (HMV) in children has increased over the last years. • Normal family functioning is usually disrupted by HMV. What is New: • The aim of HMV is to provide a lifestyle similar to that of healthy children, but perceived quality of life by these patients and their parents is low. • Most of the families caring for children on HMV agree that support and resources provided by national health institutions is insufficient.
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Affiliation(s)
- Rafael González
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Calle Doctor Castelo 47, Madrid, 28009, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
- RETICS funded by the PN I+D+I 2013-2016 (Spain), ISCIII- Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), ref. RD16/0022, Madrid, Spain
| | - Amaya Bustinza
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Calle Doctor Castelo 47, Madrid, 28009, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Sarah N Fernandez
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Calle Doctor Castelo 47, Madrid, 28009, Spain
- Gregorio Marañón Health Research Institute, Madrid, Spain
| | - Miriam García
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Calle Doctor Castelo 47, Madrid, 28009, Spain
| | - Silvia Rodriguez
- Pediatric Intensive Care Unit, Hospital Sant Joan De Deu, Barcelona, Spain
| | | | - Mirella Gaboli
- Pediatric Intensive Care Unit, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Silvia García
- Pediatric Intensive Care Unit and Home Care Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Olaia Sardón
- Pediatric Pneumology Department, Hospital Universitario Donostia-Osakidetza, San Sebastián, Spain
| | - Diego García
- Pediatric Intensive Care Unit, Hospital de Cruces, Bilbao, Spain
| | - Antonio Salcedo
- Pediatric Pneumology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Antonio Rodríguez
- Pediatric Intensive Care Unit, Complejo Hospitalario Universitario de Santiago, Santiago de Compostela, Spain
| | - Ma Carmen Luna
- Pediatric Pneumology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Arturo Hernández
- Pediatric Intensive Care Unit, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - Catalina González
- Pediatric Intensive Care Unit, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Alberto Medina
- Pediatric Intensive Care Unit, Hospital Central de Asturias, Oviedo, Spain
| | - Estela Pérez
- Pediatric Pneumology Department, Hospital Materno Infantil Carlos Haya, Malaga, Spain
| | - Alicia Callejón
- Pediatric Pneumology Department, Hospital Universitario Nuestra Señora de la Candelaria, Tenerife, Spain
| | - Juan D Toledo
- Pediatric Department, Hospital General de Castelló, Castellón, Spain
| | - Mercedes Herranz
- Pediatric Pneumology Department, Hospital Virgen del Camino, Pamplona, Spain
| | - Jesús López-Herce
- Pediatric Intensive Care Unit, Hospital General Universitario Gregorio Marañón, Calle Doctor Castelo 47, Madrid, 28009, Spain.
- Gregorio Marañón Health Research Institute, Madrid, Spain.
- RETICS funded by the PN I+D+I 2013-2016 (Spain), ISCIII- Sub-Directorate General for Research Assessment and Promotion and the European Regional Development Fund (ERDF), ref. RD16/0022, Madrid, Spain.
- Pediatrics Department, Complutense University of Madrid, Madrid, Spain.
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Graham RJ, Rodday AM, Weidner RA, Parsons SK. The Impact on Family of Pediatric Chronic Respiratory Failure in the Home. J Pediatr 2016; 175:40-6. [PMID: 27289498 DOI: 10.1016/j.jpeds.2016.05.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 04/15/2016] [Accepted: 05/04/2016] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the family impact of managing severe, chronic respiratory failure (CRF) at home. Better understanding will inform parental counseling and serve as a point of reference for interventions. STUDY DESIGN Families of children with CRF completed the Impact on Family Scale (IFS) and Consumer Assessment of Healthcare Providers and Systems. Using multivariable linear regression, we assessed the relationship between IFS and family, clinical, and utilization characteristics. RESULTS A total of 118 parents (60%) completed the IFS; 114 parents (58%) completed all measures. The 15-item IFS mean total score was 40 (SD = 10) with a possible range of 15-60 (greater scores indicate more impact). Modeling identified a negative association with parent emotional functioning, parent-rated child health, and private insurance only (compared with both private/public), and other family characteristics (eg, parental education, marital status, and income) were not associated with IFS scores. CONCLUSION Families of children with CRF are greatly impacted by their child's health. In contrast to other children with special health care needs, family characteristics were not associated with IFS scores, excluding insurance type. These results may reflect more uniform demands and stressors related to CRF. Future research should identify interventions to attenuate the impact of CRF.
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Affiliation(s)
- Robert J Graham
- Division of Critical Care, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Angie Mae Rodday
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, MA; Tufts University School of Medicine, Boston, MA
| | - Ruth Ann Weidner
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, MA
| | - Susan K Parsons
- Tufts Medical Center, Institute for Clinical Research and Health Policy Studies, Boston, MA; Tufts University School of Medicine, Boston, MA
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