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Membership Continuing Education
Evidence-Based Transition of Care Interventions for Hospitalized Children with Medical Complexity

Publication Date: 7/22/2021


Length: 60:12


Content Level: Intermediate 1 General CE


Abstract
Children with medical complexity (CMC) represent less than 1% of children, but account for one-third of all pediatric health care spending. CMC have high readmission rates, ranging from 9% - 16.8%. Our 60-bed acute care hospital is ranked highest in the state for inpatient pediatric acuity, and our health system provides outpatient and inpatient specialty care to CMC experiencing childhood-onset complex disabling conditions. An evidence-based care management program was designed to improve transition of care from hospital-to-home for the high-risk CMC population. Program impact is assessed using the outcome measures (unplanned readmission rate and patient/family experience) and care management intervention process measures. An organization-wide outpatient care management program was recently implemented, and high-need patients requiring inpatient CM are eligible for enrollment in this program. Differentiating which intervention(s) have the greatest impact on the CMC population facilitates a targeted CM program despite resource limitations.


Learning Objectives:
1. Translate ACMA Transitions of Care Standards to a pediatric population.
2. Describe the elements of an evidence-based inpatient care management program for children with medical complexity.
3. Apply concepts to design a care management program that meets the needs of your pediatric inpatient population.
4. Evaluate the impact of a care management program using pediatric appropriate measures.


Speakers
Dr. Rhonda Cady, RN, PhD
Rhonda Cady is a Nursing Research Specialist at Gillette Children’s Specialty Healthcare. She has a doctoral degree in health informatics from the University of Minnesota, a master’s degree in business information systems from the University of Wisconsin and is a licensed registered nurse in Minnesota and Wisconsin. Rhonda’s research focuses on the impact of care coordination/care management for children with medical complexity and the use of technology by nursing staff to improve care delivery for children with medical complexity.

Kari Kubiatowicz, BSN, RN
Kari Kubiatowicz is a Nurse Care Manager & Utilization Review at Gillette Children’s Specialty Healthcare. She has her BSN degree from the University of Wisconsin – Eau Claire. Kari has been a pediatric nurse for more than eight years. Kari is passionate about improving care management for children with medical complexity and has helped to advance the inpatient and outpatient care management and utilization management programs at Gillette Children’s Specialty Healthcare.

Sara Moga, MSN, RN
Sara Moga is a Nurse Care Manager & Utilization Review Nurse at Gillette Children’s Specialty Healthcare. She has a master’s degree in care coordination from Capella University and her bachelor’s degree from Globe University. Sara has been a pediatric nurse for 6 years. Sara is passionate about providing patient centered care management for complex pediatric patients and their families by empowering and educating them to understand and navigate the healthcare system.

Keywords: transitions of care, children, medical complexity, pediatric

Evidence-Based Transition of Care Interventions for Hospitalized Children with Medical Complexity

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