Comprehensive Transitional Medical Home for Medically Fragile
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Comprehensive Transitional Medical Home for Medically Fragile I nfants: Redesigning the Model for Post-discharge Care. Ricki F. Goldstein MD Professor of Pediatrics Director, High-Risk Infant Follow-up Program and Special Infant Care Clinic Division of Neonatology

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Comprehensive Transitional Medical Home for Medically Fragile Infants: Redesigning the Model for Post-discharge Care

Ricki F. Goldstein MD

Professor of Pediatrics

Director, High-Risk Infant Follow-up Program and

Special Infant Care Clinic

Division of Neonatology

Duke University Medical Center

The problem
The Problem Fragile

  • Extremely premature and critically ill term infants

    • discharged home with a complex mix of pulmonary, cardiac, gastrointestinal, endocrine and neurologic problems

      • Multiple medications

      • Complicated feeding regimens

      • Special equipment

      • Limited insurance coverage for nursing care

    • Few pediatricians and family medicine physicians have the training, experience, and availability to optimally care for these fragile infants during their most vulnerable first year of life.

Present system of care
Present system of care Fragile

  • Frequent lack of continuity of primary care

    • house-staff clinics

    • large pediatric and family medicine practices

    • health departments

  • Multiple subspecialty clinic appointments scheduled soon after discharge

  • Frequent visits to the emergency room for acute problems (triaged at night)

  • Inconsistent quality of community case management

  • Poor communication, fragmentation and/or duplication of care

Consequences Fragile

  • Delayed or ineffective care

    • acute illnesses or complications develop into severe, even life-threatening problems

    • feeding and nutritional difficulties lead to failure to thrive

  • Frequent use of emergency room

    • Evaluated by physicians unfamiliar with neonatal problems

    • Multiple visits with eventual admission

  • Rehospitalization

    • Often straight to PICU

S olution
S Fragile olution

  • Comprehensive Transitional Medical Home (TMH)- funded by The Duke Endowment

    • Tertiary care medical center team

    • Health care providers with special training, experience, availability and commitment

    • Medical follow-up during “transitional” period between neonatal hospitalization and care by general pediatric medical home

      • Chronic medical problems more stable

      • Growth and nutrition established

      • Parents more comfortable and confident

Goals of tmh home program
Goals of TMH Home Program Fragile

  • Maximize long-term medical and developmental outcomes

    • Comprehensive medical care

    • Improved community case management

  • Decrease overall cost of post-discharge medical care

  • Educate well-child care providers in the long-term care of infants with complex medical problems

Research Fragile

  • A large, single-center randomized trial of comprehensive care for preemies in Dallas

    • Well-baby care

    • Acute and chronic illnesses and complications

    • Experienced physicians and nurse practitioners,

    • Available 5 days/week in clinic and by pager 24/7

  • Results

    • Substantially reduced life-threatening illnesses resulting in death or admission to a PICU

    • Reduced cost of post-discharge care during the first year of life.

      Broyles et alJAMA 2000;284:2070-6.

Research Fragile

  • Children’s hospital-based multidisciplinary clinic in Kansas

    • provides comprehensive and coordinated care for medically complex children

    • ensures that each patient receives all necessary medical, nutritional, and developmental care

  • Results

    • Significant decrease in total Medicaid costs

      Casey PHet al. Arch Pediatr Adolesc Med. 2011;165(5):392-398.

Proposed tmh model of care
Proposed TMH model of care Fragile

  • Immediate medical follow-up within 1-3 days after discharge.

  • Co-management of acute illnesses related to neonatal problems(ability for next day visit)

  • Surveillance and treatment of chronic medical problems with coordination of consulting sub-specialist visits when needed.

  • Ongoing feeding and motor evaluations and arrangement for intervention services

Proposed tmh model of care1
Proposed TMH Fragile model of care

  • 24/7 pager availability, by experienced physician or nurse practitioner familiar with the babies' medical problems

    • Parents to call with questions and acute problems

    • Primary care provider when seeing child

    • ER physicians

    • Admitting hospital

Eligibility criteria
Eligibility criteria Fragile

  • Extreme prematurity:

    • Less than or equal to 26 weeks gestation at birth

  • Chronic medical problems in premature or term infants

    • Chronic lung disease of infancy

    • Feeding problems (e.g. G-tube, NG tube, severe gastroesophageal reflux, dysphagia)

    • Surgical necrotizing enterocolitis, other short-gut syndrome

    • Severe respiratory failure

      • ECMO

      • Congenital diaphragmatic hernia with PPHN

    • Congenital heart disease requiring delayed or multi-staged correction (in future)

  • Severe brain injury

    • Hypoxic ischemic encephalopathy

    • Severe intraventricular/intracranial hemorrhage

    • Periventricular leukomalacia, neonatal stroke

Evaluation of tmh program
Evaluation of TMH Program Fragile

  • Acute illnesses (type and how treated)

  • Growth during first year

  • Timeliness of immunization administration including Synergis and Flu shots

  • Emergency room visits (reasons and outcome)

  • Sub-specialty clinic visits (type and number)

  • Rehospitalizations, including but not limited to PICU stays (reasons and length of stay)

  • Early intervention services (type, when initiated)

Evaluation of tmh program1
Evaluation of Fragile TMH Program

  • Nature of phone calls received from parents and the outcome of advice given.

  • Nature of phone calls received from WCC providers or outside ER’s and the outcome of advice given.

  • Neurodevelopmental outcome at 9-12 months of age

  • Cost of all medical care during the first year after discharge (including primary care and specialty visits, acute care, hospitalizations, ER visits, medications, etc)

Measureable goals
Measureable goals Fragile

  • Improve continuity of care and decrease duplication of services

    • compare number of different well-child care and sub-specialty providers over first year

  • Decrease emergency room visits

  • Decrease number of and length of stay during rehospitalizations to Duke or other hospital

  • Decrease PICU admissions and length of stay

  • Measureable goals1
    Measureable goals Fragile

    • Improve medical and developmental outcomes of our most medically fragile NICU (and eventually PCICU) graduates.

    • Decrease post-discharge cost to third party payers for NICU and PCICU graduates medically fragile infants during the first year of life.

    P resent and future partners
    P Fragile resent and future partners

    • North Piedmont Community Care Network

      • Local post-discharge visits and early coordination of care

      • Initial communication with case managers in other counties

      • North Carolina Children’s Accountable Care Collaborative

        • Hospital based case manager to serve as liaison to all medical providers and community agencies

        • Work closely with TMH program to improve outcomes and decrease cost of care for Medicaid patients.