Cincinnati Children’s Hospital Medical Center
At the same time Cincinnati Children’s Hospital Medical Center (CCHMC) became involved in the CARE Award, the hospital launched a care management program focused on the highest-risk patient population across four care centers. This provided the organizational structure and technology support to integrate care coordination competencies across the continuum.
Aligning care coordination model within the continuum of care
Care coordination was historically housed in specialty clinics with nurses or social workers focused on a specific disorder or condition, or inpatient units to support patients at discharge. Anchoring the complex care and care management model within primary care supports the Primary Care Medical Home model where primary care practice serves as a hub for care coordination.The tools and model were developed within primary care, and scaled and spread from there. This created a centralized place to support programs like Transitions of Care from Hospital after admission to home.
Making the case for adoption of a system-wide model
Some factors spurring adoption of this model came from the larger landscape within and outside the organization. Inside was the redesign of CCHMC’s primary care system, redesign of chronic disease and complex patient management, and launch of an accountable care organization-like health model. Each tactic was in progress and elevated the role of care coordination to care for high-risk and high-cost patients with medical complexity. Finally state payment models like Comprehensive Primary Care (CPC) were supporting the concept of risk stratification and care coordination for high-risk and high-cost payments, which further supported the model adoption.
Transformation aspects needed to assure continued delivery system evolution
The use of, and contribution to, the Longitudinal Plan of Care (LPOC) across CCHMC will be helpful as a source of core information about patients and families, their goals and key aspects of care. The CCHMC team will further promote using the EPIC-based tools to support care coordination outside of primary care, ensure access and emergency plans are easily available for all team members - including My Chart for patient and family access - provide continued revision and refinement of care management practice guidelines that define roles, and monitor how interactions occur between primary care and specialty providers.
How the CARE Award supported process changes
There is tremendous variation in how and where care managers document their practice. Learnings from the other awardees helped to inform work around optimizing EPIC tools, updating Care Manager Practice Guidelines and providing supportive accountability in supervision. Input from CARE Award sites on their model and practices also allowed opportunities for more proactive practice with respect to continual assessments. They shared that every interaction is an opportunity, encouraged dynamic care team core members to be included on the access plan and integrated with the care delivery team, offered ideas for transitions of care between in- and outpatient settings, and supported the creation of Care Manager EPIC Dashboard.
Family engagement in the new care model
The CCMHC team focused on 1) family relationship development with the care managers and 2) testing and implementation of the change concepts. Family relationship development was an ongoing process, and emphasized the importance of developing collaborative partnerships between patients, families and care managers. Families were involved one-on-one with care managers, actively engaged in Plan-Do-Study-Act (PDSA) activities in real-time, and their feedback incorporated into all PDSA cycles.
Family feedback was used in planning and practice guideline development, and parents served as either intermittent or continuous reviewers of PDSA cycles. They were engaged at visits by one of their primary care team members, and then received follow-up calls. Their providers explained care management services, and that parental involvement and ideas were essential.
Families were also engaged through co-production of patient-stated goals for the LPOC that allowed reinforcement of patient and family preferences. Families were appreciative of access planning, which gave them more confidence in managing their child’s care. Having an accountable point of contact improved the family’s connection to their clinics and ensured their needs were addressed. Parents on the project team confirmed that family input is important and brings a different and valued lens to patient care. Families shared feedback that validated the utility and value of the current care management model, its practices and the importance of establishing sound relationships with care managers, providers and care team members.
Read more about Cincinnati Children’s program: Proactive Care Management Promotes Quality Outcomes for Patients with Medical Complexity