Abstract
Problem/Purpose: Health systems are challenged to provide and lead care coordination for patients with efficient, effective discharge plans. All healthcare systems need care coordination programs focused on high-risk patient populations to help throughput. A family-centered team approach can be used for children with complex healthcare needs. The purpose of this presentation is to describe a hospital-based care coordination program; outline implementation strategies and processes; discuss staffing mix; and share lessons learned and future visions.
Program Description: A hospital-based care coordination program for children with complex healthcare needs was developed over 20 years ago in an academic medical center in the Midwest United States. Care coordination problems in primary care were resulting in negative patient outcomes; for example, primary providers felt care was fragmented and lacked coordination leading to missed appointments, care delays, and miscommunication. Families reported not feeling prepared for discharge, variations in discharge instructions, and dissatisfaction with care process transitions. Given patient complexities and financial challenges in health care today, new models of efficient, cost-effective, family-oriented care coordination are critical.
Evaluation: Core program components include a dedicated coordinator; standardized discharge processes; devoted resources; and clear communication and escalation processes. Since 2001, 9,000 children have been served with common diagnoses being tracheostomy, genetic disorders, and complex cardiac conditions. Current inclusion criteria are patients having 3 or more services involved and/or a condition/disease lasting at least 1 year. Staffing ratios are 1 coordinator to 15-20 patients. Total hospital charges have been reduced by an estimated $3 million (35% decrease).
Implications: Care coordination programs are critical in aligning discharge processes with positive family and organizational outcomes. While some challenges remain for managing a high-performing care coordination program, healthcare systems need new efficient, cost-effective, and family-oriented modes of healthcare delivery. Sharing program development allows for expansion to more healthcare areas across the care continuum. Lessons learned can be valuable when outlining the core components needed to develop successful care coordination programs that can be replicated for other high-risk patient populations.
Notes
References:
1. Brooks, E. M., Winship, J. M., & Kuzel, A. J. (2020). A "behind-the-scenes" look at interprofessional care coordination: How person-centered care in safety-net health system complex care clinics produce better outcomes. International Journal of Integrated Care, 20(2), 5. https://doi.org/10.5334/ijic.4734
2. Khatri, R., Endalamaw, A., Erku, D., Wolka, E., Nigatu, F., Zewdie, A., & Assefa, Y. (2023). Continuity and care coordination of primary health care: A scoping review. BMC Health Services Research, 23(750), 1-13. https://doi.org/10.1186/s12913-023-09718-8
3. Petitgout, J. M. (2018). The financial impact of a hospital-based care coordination program for children with special health care needs. Journal of Pediatric Health Care, 32(1), 3–9. https://doi.org/10.1016/j.pedhc.2017.06.003
4, Simpson, K., Nham, W., Thariath, J., Schafer, H., Greenwood-Eriksen, M., Fetters, M. D., Serlin, D., Peterson, T., & Abir, M. (2022). How health systems facilitate patient-centered care and care coordination: A case series analysis to identify best practices. BMC Health Services Research, 22(1448), 1-17. https://doi.org/10.1186/s12913-022-08623-w
Sigma Membership
Non-member
Type
Presentation
Format Type
Text-based Document
Study Design/Type
Other
Research Approach
Other
Keywords:
Interprofessional Initiatives, Interprofessional, Interdisciplinary, Acute Care, Care Coordination Programs
Recommended Citation
Petitgout, Janine Marie, "Care Coordination: 20 years of Lessons Learned and Future Visions" (2025). International Nursing Research Congress (INRC). 15.
https://www.sigmarepository.org/inrc/2025/presentations_2025/15
Conference Name
36th International Nursing Research Congress
Conference Host
Sigma Theta Tau International
Conference Location
Seattle, Washington, USA
Conference Year
2025
Rights Holder
All rights reserved by the author(s) and/or publisher(s) listed in this item record unless relinquished in whole or part by a rights notation or a Creative Commons License present in this item record.
Review Type
Abstract Review Only: Reviewed by Event Host
Acquisition
Proxy-submission
Care Coordination: 20 years of Lessons Learned and Future Visions
Seattle, Washington, USA
Problem/Purpose: Health systems are challenged to provide and lead care coordination for patients with efficient, effective discharge plans. All healthcare systems need care coordination programs focused on high-risk patient populations to help throughput. A family-centered team approach can be used for children with complex healthcare needs. The purpose of this presentation is to describe a hospital-based care coordination program; outline implementation strategies and processes; discuss staffing mix; and share lessons learned and future visions.
Program Description: A hospital-based care coordination program for children with complex healthcare needs was developed over 20 years ago in an academic medical center in the Midwest United States. Care coordination problems in primary care were resulting in negative patient outcomes; for example, primary providers felt care was fragmented and lacked coordination leading to missed appointments, care delays, and miscommunication. Families reported not feeling prepared for discharge, variations in discharge instructions, and dissatisfaction with care process transitions. Given patient complexities and financial challenges in health care today, new models of efficient, cost-effective, family-oriented care coordination are critical.
Evaluation: Core program components include a dedicated coordinator; standardized discharge processes; devoted resources; and clear communication and escalation processes. Since 2001, 9,000 children have been served with common diagnoses being tracheostomy, genetic disorders, and complex cardiac conditions. Current inclusion criteria are patients having 3 or more services involved and/or a condition/disease lasting at least 1 year. Staffing ratios are 1 coordinator to 15-20 patients. Total hospital charges have been reduced by an estimated $3 million (35% decrease).
Implications: Care coordination programs are critical in aligning discharge processes with positive family and organizational outcomes. While some challenges remain for managing a high-performing care coordination program, healthcare systems need new efficient, cost-effective, and family-oriented modes of healthcare delivery. Sharing program development allows for expansion to more healthcare areas across the care continuum. Lessons learned can be valuable when outlining the core components needed to develop successful care coordination programs that can be replicated for other high-risk patient populations.
Description
This presentation is intended for leaders in healthcare systems struggling with care coordination to meet complex patient and throughput needs. We will share a story of developing and sustaining a care coordination program for high-risk pediatric patients in an academic medical center. Core program components, lessons learned, and future visions from a successful 20-year care coordination program will be shared with participants to utilize and replicate across populations and settings.