• Article
  • May 23, 2017

Creating Medical and Psychosocial Goals for Patients With Medical Complexity

This is the third installment in a series on the CARE Award: "Coordinating All Resources Effectively." CARE is the basis of a national hallmark study aimed at improving quality outcomes and reducing costs of care for children with complex medical conditions enrolled in Medicaid. CHA partners with 10 of the nation's hospitals on the CARE program, which encompasses more than 8,000 patients, as well as their caregivers and health care payers. 

Today, we check in with one of CARE's participating institutions, Children's Hospital Colorado in Aurora, Colorado.

Goal setting is an important part of the patient care plans that Scott Bates, M.S.W., social work care coordinator at Children's Hospital Colorado, and his team build for the roughly 1,700 CARE-enrolled patients they see. But like those patients, the goals can be different.

Bates recently shared the story of one grief-stricken patient with his CARE program colleagues. The child's father had been deported to Mexico, and the boy was having a hard time coping. He set a goal to visit a former teacher with whom he'd established a tight bond. It wasn't a medical goal, but Bates and his team made it happen because they knew the psychological benefits were worth the investment.

Growth poses challenges

That child, along with about 3,700 others, is a patient of Children's Hospital Colorado's complex care unit, the Special Care Clinic (SCC). According to Christopher Stille, M.D., MPH/MSPH, section head of General Academic Pediatrics, who oversees the primary care clinics at Children's Colorado, SCC is one of the nation's oldest and largest pediatric complex care clinics.

Since opening in 2001 with about 1,200 to 1,400 patients, it's nearly tripled the number of children in its care. Such growth presents challenges for the hospital. SCC provides primary care for half of these children, and the rest of the visits are either co-managed or consultative.

"We have to face the reality that we're the only major referral center in a really big area," says Stille. "Our biggest challenge is managing size and managing resources to go with that size. The identification for our primary care kids to graduate and safely transition to community pediatric practices helps us manage our clinic size."

An integrated approach

Despite the growing pains, SCC accepts about 85 percent of the roughly 60 referrals it receives each month. Those under SCC care benefit from the clinic's Multiple Appointment Resource Team (MART), which helps coordinate appointments across multiple specialists on the same day. Each patient also receives an individualized care plan that takes into account not only the child's physical needs but also the social determinants of health.

As part of the registration process, parents complete a psychosocial screening, and the results are included in the electronic health record where providers review them. The appropriate team member implements the care pathway. "The screening is being implemented for all patients at the Special Care Clinic," says Bates. "That information helps our nurse care coordinators connect the dots with these folks so there is some good focus, not only on the medical side, but also on the social-behavioral goals that we know are important for our families."

Words of advice

Stille and Bates share some advice for other institutions looking to improve, or even begin, their own program for caring for pediatric patients with complex medical conditions:

  • Involve parents early. Bringing in the parents' perspectives early in the process can make the formulation of the care plan more efficient and reduce "wheel-spinning."
  • Promote care coordination. Make sure patient families and providers are on the same page regarding the coordination of care; this will clear up possible confusion about the process.
  • Hold "Breakfast Clubs." SCC conducts regular morning gatherings for care providers, where they are treated to breakfast by the clinic. The team uses that time to complete their portion of the care plan work, streamlining the process for the care coordinators and speeding delivery of the plans to families.
  • Consider the physical layout. Don't underestimate the importance of the physical layout of your clinic. Consider the importance of teamwork among the doctors, nurses and care coordinators, and, if possible, design a center that enables collaboration.

About CARE

In partnership with 10 of the nation's leading children's hospitals, the Children's Hospital Association received a three-year $23 million Health Care Innovation Award from the Center for Medicare and Medicaid Innovation. Of the roughly 3 million medically complex children nationwide, two-thirds are covered by Medicaid. These 2 million children represent nearly 40 percent of costs. They are clinically fragile and have intense medical and care coordination needs that are not always met by existing care delivery and payment models. 

Send questions or comments to magazine@childrenshospitals.org.

Read other CARE hospital case studies.



This publication was made possible by Grant Number 1C1CMS331335 from the Department of Health and Human Services, Centers for Medicare & Medicaid Services. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies. Pub # 3114, Approved 4/27/17