Clinical integration is the coordination of patient care across the care continuum. It involves coordination of care not only between providers, but also between care settings (for example, between the clinic and the hospital, the hospital and the pharmacy, the hospital and rehabilitation facility, the hospital and home health care). Below are examples of clinical integration programs or initiatives at Children’s Health℠.
Asthma Management Program
The Asthma Management Program is an outpatient educational program that helps parents and caregivers learn how to manage their child’s asthma. The program focuses on asthma education and self-management skills, and it integrates care between the nurse care coordinator, the family, the primary health care provider, the school nurse, teachers, coaches and any other caregivers. The partnership with the referring provider is a key component of the program.
The Asthma Management Program includes:
- Six months of biweekly telephone contacts by a Certified Asthma Educator (RN).
- Two home visits by an asthma specialist to provide asthma education about medications and other common triggers that may make a child’s asthma worse, including smoke and ozone.
- The asthma specialist also looks for triggers in the home and teaches ways to eliminate them, and provides the family with various asthma tools to help better manage the child’s asthma.
Center for Autism and Developmental Disabilities
The Center for Autism and Developmental Disabilities (CADD) is dedicated to improving the lives of individuals with autism or other developmental disabilities through the integration of cutting-edge research, comprehensive clinical care and first-rate training of the next generation of scientists and care providers.
The CADD evaluates children who have a suspected autism spectrum disorder with a focus on early detection and offers comprehensive clinical services including intake, psychological testing, diagnosis and treatment.
Clinical pathways standardize key elements of care for patients with common diagnoses, thereby reducing variations in care. The pathways use proven best practices to establish recommended processes for care.
In 2012 and 2013, Children’s Health developed and introduced clinical pathways for three of the most common diagnoses treated: bronchiolitis, appendicitis and asthma.
Each pathway development team was comprised of individuals from a wide variety of disciplines and took into account the full continuum of care—from the patient’s primary care office visit, through their treatment at Children’s Health, and back again.
These are the results of our initial efforts:
- Patients who are being treated through the appendicitis pathway require less radiographic imaging and post-operative antibiotics.
- The average length of stay for patients treated through the bronchiolitis and asthma pathway has decreased.
The goal of Home Care is to transition the child from the hospital to the home as soon as it is safely possible. Home Care allows the child to go home to familiar surroundings, yet have continuing access to high-quality care outside of the hospital.
Some of the services provided by Home Care include:
- Skilled nursing: Provides intermittent visits for skilled services such as IV infusion therapy, tracheotomy care, G-tube care, ostomy care, central line/PICC care, wound care, diabetic care, pre- and post-operative care and catheter care.
- Occupational therapy: Helps to improve fine motor skills, sensory integration, self-care skills and activities of daily living.
- Physical therapy: Helps to improve gross motor development, balance and strength, coordination, functional mobility, and ambulation.
- Speech therapy: Helps with speech and language, feeding and swallowing difficulty and cognitive and social deficits.
- Clinical respiratory services: Provides respiratory equipment and education.
Children’s Health℠ Pediatric Group
The focus on improving the health of children in the community begins with establishing a high-quality and affordable patient-centered medical home for every child in the region. The Children’s Health Pediatric Group network now serves as that medical home for families in more than 16 different locations. Children’s Health Pediatric Group offices are open to all children and accept most forms of insurance, including Medicaid and Children’s Health Insurance Program (CHIP).
- Newborn care
- Well-child exams
- Asthma management
- Care coordination
- Comprehensive evaluation and treatment of pediatric illnesses
The Children’s Health Pediatric Group team is in the process of redesigning its overall approach to primary care delivery. This new care model includes telemedicine and virtual office visits. The model integrates more advanced medical care into the primary care setting, delivers services through schools and faith-based organizations, and enhances family engagement.
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