Single Plan of Care Connects Children's Hospital and Community Partners

Single Plan of Care Connects Children's Hospital and Community Partners

How one children’s hospital connected primary and specialty care physicians, school nurses and others for improved care coordination.

Statistically, a small percentage of patients end up in a children’s hospital. But, as more children’s hospitals arrange into accountable care networks (ACN) and develop community partnerships, more patients could be eligible for formalized care coordination plans. Michael Weiss, D.O., vice president of population health at CHOC Children’s Hospital in Orange County, California, says care coordination is traditionally for high-risk patients. But for it to be successful and sustainable, hospitals may need to offer it to more populations.

“We made a commitment four years ago that our population health division is not going to focus only on high-risk patients,” Weiss says. “Only 5%-7% of children will need the services of a tertiary or quaternary facility. We felt care coordination needed to encompass all children in our county.”

For CHOC, more patients utilizing care coordination meant an increase in communication challenges. CHOC developed a process for single communication across community partners to ensure every provider had the same level of information for consistent patient care.

A single plan of care

CHOC is nearly three years into streamlining communication by implementing a single plan of care, where all community partners have visibility to the same system.

“If a child is seen by primary or specialty care, it’s in the system,” he says. “We recently allowed secure access to our electronic medical record (EMR) to school nurses so they can use information from our specialty clinics to inform their individualized education plans and emergency plans for children with diabetes and seizures. This is what carries the care coordination system across the spectrum.”

Community physicians can also gain access to read-only versions of the single plan of care. Weiss, a former general pediatrician, says this helps accommodate for gaps in care between appointments. “When I saw a very sick child, the first thing I would say to that mom after not seeing them for four to six months is, ‘What’s happened since I saw you last?’” Weiss says. “That’s the worst thing you could ever say in this day and age of communication.”

With a single plan of care, any physician can access the patient’s EMR to prepare and know what’s happened since the last visit. Included in the single plan of care is:

  • Key personal information. This can include a child’s nickname, favorite sports team or color, the name of a pet. The goal is to give the provider a piece of information that can break the ice and help patients feel comfortable.
  • Preferences and health concerns. Often when a shift change occurs, parents must repeat their child’s medical preferences. Noting preferences—such as the child doesn’t like an IV in his or her right hand or likes the bed elevated—can make a difference in a family’s experience.
  • Equipment. Staff asked to document sizes of lines, tubes and drains used on a patient, who put them in and when, vendors for home equipment and more.
  • Ambulatory patient follow-up. When a child leaves the hospital, medical staff wants to know which appointments were made. CHOC uses a metric called “connectivity”, the percent of those appointments that are completed.
  • Disease registries. These allow the care team to assess where there are gaps in care. For example, if an asthmatic patient’s primary care physician doesn’t complete an asthma action plan, it can be completed in the hospital.

Weiss says because most care coordination programs are grant-funded, they’re short term. It’s difficult to keep these programs going and see the long-term effects they can have on pediatric patients.

“We all have great ideas around care coordination and moving toward value-based payment,” Weiss says. “We have an opportunity to start looking at our programs and develop the argument that investing in care proactively has a return on the investment.”

The value proposition

While implementing the single plan of care, it’s crucial to get buy-in from providers. Weiss says nobody is vying to offer pediatric physicians more money to do more work for the same number of patients. To get physicians on board, leadership must discover what matters most to physicians, which commonly falls into three categories:

  • Altruism. Weiss says there is a subset of physicians who are willing to do the extra work solely to improve the quality of care for their patients.
  • Community. Pediatrics is small, in terms of revenue and population base. Becoming part of a greater community of pediatric physicians can lead to a larger investment in change.
  • Quality of life. When value-based care is done effectively, physicians should experience a reduction in stress and a better work-life balance.

“You don’t know what’s important to the doctor until you ask them,” Weiss says. “It’s a valuable question.”

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