Pediatric Care Coordination Continuum - PowerPoint Presentation

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Pediatric Care Coordination Continuum

Jorge

Ganem

Valerie

Jurgens

Toni Wakefield

Kirsten Nieto

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Medically Complex Care

Subspecialty Referrals

Transitions to Adult Providers

Reducing Readmission

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Coordinating inpatient care

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Quick Look

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www.dellchildrens.net

“I Am A…Healthcare Professional”

Direct admission

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Dell Children’s Transfer Center

(512)–

324-3262 (DCMC)Direct AdmissionsConsultationsPCRS (Hospital Medicine), Emergency Department, Pediatric Intensive Care

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Evidence-Based care Guidelines

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www.dellchildrens.net

“I Am A…Healthcare Professional”

Evidence-Based Guidelines

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Search google for DCMC Evidence-Based Guidelines (available on internet) – see below

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Guidelines for Common Diagnoses

Abnormal Uterine Bleeding

AppendicitisAsthmaBronchiolitis

Febrile Infants

Kawasaki Disease

Orbital Cellulitis

Osteomyelitis

Pneumonia

Urinary Tract Infections

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Up to Date Review of Literature

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Practice Recommendations

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Admission Criteria

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Management Pathway

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www.dellchildrens.net

“I Am A…Healthcare Professional”

Specialty Referral Recommendations

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Recommendations by Subspecialty

Adolescent Medicine

CardiologyDermatology

Endocrinology

Gastroenterology

Nephrology

Pediatric Gynecology

Pediatric Surgery

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Management and Referral Guidelines

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Management and Referral Guidelines

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Accessing Seton Intranet from offsite

https

://

www.seton.net/seton-associates

“Citrix”

“Log-in” with your user and password

Click Seton Intranet

Setonville

Seton intranet will open

Want to Access Seton Intranet for other protocols

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For DCMC

Antibiogram

: 1. Clinic “clinical.” 2. “Department” 3. “Pharmacy DCMC”

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Coordinating care in medically complex

children

DCMC Children’s Comprehensive Care Clinic

Currently

accepting new patients with high medical complexity.

To

refer to our clinic please call 512-628-1898 or fax 512-600-8149 (Attention: Referral to CCC).

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Patient/ Family

Case Manager

Multidisciplinary assessment

Annual Care plan Update and goal setting

Person-centered planning

Data sharing across sectors

Case Management and service coordination tied to the patient (not agency or service line)

Collective accountability for outcome

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Case Management

Behavioral Health

Community

Medical (PCP/Specialist)

Therapy/ Habilitation

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Case Management

Behavioral Health

Community

Medical (PCP/Specialist)

Therapy/ Habilitation

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DCMC Multi-specialty, Multi-disciplinary Clinics

for Children with Medical Complexity

Specialty

Care Center 2nd

Floor DCMC;

4900 Mueller

Blvd

;

512-324-0137

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DCMC Unique

Specialty Clinics

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Preventing readmissions

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Transitions of care

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DCMC Coordination with Adult Providers

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Specially for Children Pediatric Endocrinology Clinic

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Endo Clinic Transition QI Timeline

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Transition Policy

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Transition Registry

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Who to Transition?

Age

Type 1 DM

Type

2 DM

Total DM

>18 years

185

35

22016-17 years15550

205

14-15 years14832180

488117605Other Diagnoses to Consider for Transition Project (n=#18+)

Thyrotoxicosis (10)Thyroid Cancer (5)Panhypopit (11)

Pituitary Dwarfism (11)Anterior Pituitary Disorders (11)Androgenital abnormalities (9)Glucocorticoid deficiency (6)

MEN (0)Hyperparathyroid

Other pituitary diagnoses

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Goiter

Hypothyroid

Calcium

Lipid disorders

Menstrual disorders

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Patient Readiness Assessment

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Provider Readiness Assessment

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SFC Endocrine Clinic Process

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SFC Endocrine Clinic Process