PM2015: A Palliative Model for Medical Complexity: Palliative Team to Population Health Center

Purpose/Objectives: There is a population of children - known by titles such as Children with Special Healthcare Needs, Children with Medical Complexity, Children with Complex Chronic Conditions, and Children with Technological Dependency - who require a large proportion of hospital days and Medicaid expenditures in order to retain good quality of life. These patients, often referred to Pediatric Palliative Care teams for goals of care conversations and supportive care, often lack a medical home or a comprehensive coordination model to guard their decisions and outcomes. Our team piloted a Palliative Care centric Medical Home model for coordination of patients' care and then studied outcomes based on that intervention to test the new model.

Design/Methods: Quality Improvement study design consisted of choosing patients for the pilot based on complexity scores assigned by the Chronic Illness & Disability Payment System (CDPS) score. We selected from a list of highest scores and our average selection was a 7 on the CDPS scale, meaning that the patient had seven times the typical complexity of an average child. We then instituted a team and coordination model based on our small Palliative Care team. This consisted of a Social Worker, Nurse Coordinator, Respiratory Therapist, Advanced Practice Provider, and a Physician. We also added a Patient Navigator to act as a proactive ambassador to families in our program - calling them weekly to check on outcomes and needs. We then viewed health data aggregated from our EHR on trends of Emergency Room utilization, Follow-Up timeliness, and wellness visits.

Results: After 6 months of program operation, and before adding additional staff and beginning the next phase of the pilot, we recorded results based on our EHR observations. What we found was astounding - a 470% increase in hospital discharge follow-up, a 47% decrease in ED utilization, and a 31% increase in emergency discharge follow-up. While our wellness attendance had a 10% 'per-year' decrease, this was easily attributed to having only been through half the year and we anticipated that in another 6 months, we were on track to significantly improve wellness attendance overall. We were also able to describe several near misses and difficult case which had been caught by the new model of patient-centered, palliative-derived, population health.

Conclusion/Discussion: In conclusion, a model of Population Health based on Palliative Care principles and a Palliative team model was able to improve outcomes significantly for a group of children with the highest levels of medical complexity. Next steps for the study will be to increase the team members to provide even more patient centered care and to evaluate overall cost-based savings to the patients as a whole. Further, if successful this model could be expanded to more patients, locations, and spectrums of medical complexity.