A Virtual Care Coordination Clinic for Children with Medical Complexities

Nationwide 3 million children are classified as medically complex, which is defined as three or more diagnoses or conditions. While this pediatric population accounts for a small percentage of the overall patient population, they are the highest utilizers of medical services. For example, complex pediatric patients represent 6% of children enrolled in Medicaid but 40% of healthcare dollars spent. At one quaternary pediatric hospital only 7.2% of patients were considered to have moderate or high medical complexity but accounted for 80% of total fixed and variable costs. This population of patients is characterized by poor coordination across a care continuum that includes subspecialists, general pediatricians, and community providers. Poor coordination has resulted in limited and timely access to needed healthcare services that translates into higher rates of hospitalization and emergency room use.

In response, a quaternary pediatric hospital supported the creation of a virtual clinic tasked with meeting the care coordination needs of this growing pediatric population. This interdisciplinary team overseen by an RN coordinator includes a physician, social worker, care coordinator, case manager, scheduler, and parent mentor. Over 400 of the most medically complex patients at this hospital are enrolled. The virtual clinic acts as a care coordination "hub," assuring good care coordination and communication among subspecialties, home health services, community providers, as well as patients and families. Virtual clinic team members flex the care they give each day by meeting patients and their families in subspecialty clinics, the hospital, and, at times, the community, to assure coordination and communication across the care continuum. Virtual clinic strategies include attendance of medical rounds, admittance and discharge summaries, discharge of phone calls within 72 hours to determine care needs, co-managed clinic visits, quarterly monitoring of calls to parents regarding care coordination needs, provider contact list for parents, post-emergency room visit phone call to the parent, and clinic visits scheduled per parent preference.

Unique to this work is the self-management training each family receives from parent mentors in their native language. Self-management training provides information, resources, and strategies that enable parents to coordinate their child's care without the assistance of health care providers. This array of services has resulted in a number of outcomes over a 3-year period: emergency room visits have decreased by 20% each year, inpatient hospitalizations have decreased by 10-15% each year, and 200 patients have been "graduated" from the program with the acquisition of self-management skills. As part of overseeing the virtual clinic, the RN coordinator implemented a series of improvements that resulted in more efficient team functioning, thus permitting an increase in the number of highly complex patients enrolled from 100 to 300. Under the leadership of the RN coordinator, the virtual clinic has successfully met the needs of complex patients and their families while reducing health care costs.