The Problem
Children with medical complexity (CMC) are the most medically fragile and costly pediatric population, and many of these CMC require frequent, prolonged hospitalizations. CMC with high hospital utilization (HHU) can benefit from value-based models that deliver efficient inpatient care and extend outside hospital walls to seamlessly coordinate care across the inpatient/ outpatient (IP/OP) continuum.
Our Solution
The primary aims of the MCCP project were to improve parent engagement, and to improve the parent experience. Essential features of the MCCP platform included:
- Read-only copy of the most updated care plan. This feature allowed families to directly view electronic copies of the MCCP online (via My Chart), and print hard copies of the MCCP to share with other care team members as needed (e.g., out-of-network PCP without access to Epic).
- Enhanced bi-directional communication/messaging for between-visit contacts. This feature leveraged existing EHR tools such as InBasket and MyChart to allow families to directly message the CCS team with real-time updates (e.g., clinical status, medication changes, etc.) that could then be efficiently incorporated into the MCCP.
- Continued integration with Maestro Care. To maintain clinical relevance and visibility, care plans continued to live in the EHR.
- Pre-visit planning questionnaires. This bi-directional communication system for real-time updates from parents allowed them to directly communicate their most pressing concerns before upcoming clinic visits.
Impact
We enrolled 60 patients enrolled in CCS (as of 3/22/17/)
- 72% (n=43) of all CCS patients were eligible to receive MCCPs
- 88% (n=38) of eligible patients received an MCCP
- 93 unique MCCPs sent by CCS team between 9/1/16 – 3/22/17
• Mean MCCPs per patient = 2.4 (range 1-6)
We found that 66% (n=25) of parents of eligible patients who received a MCCP opened/reviewed it online (surrogate for parental engagement), and that 52% (n=13) who opened/reviewed MCCP online sent a follow-up message back to CCS team (highest level of parental engagement)
The CCS response time to parental follow-up messages regarding MCCP was 2.18 hours (IQR 0.3-15.6).
