(From the March 2013 Issue of MedStat)
As you may be aware, Nationwide Children’s has recently been awarded a grant from the Center for Medicare and Medicaid Innovation (CMMI). The main goal of the grant is to implement interdisciplinary practices related to population health management in partnership with primary care physicians (PCPs), in order to decrease inpatient hospital days, improve nutritional status and make certain that community resources are being utilized completely by children with complex medical needs. This program is being administered in conjunction with Partners for Kids under the leadership of Drs. Sean Gleeson, Garey Noritz and Lee Budin.
We are going to be contacting families of patients with feeding tubes and complex neurologic diagnoses to develop care plans and goals. The purpose of these contacts will be to assess current services that are in place as well as additional potential services which might be helpful. Although we have contacted a few patients already to learn how to do this well, moving forward, we will be sending letters to the patients’ PCPs prior to contacting families. We invite PCPs to participate in developing the care plans to ensure we build upon the work initiated by the PCPs. After completion of the care plan, PCPs will be sent a copy, and again, they will be invited to further inform the care plan with their thorough knowledge of the patients. It is our plan to promote PCP offices as the medical home and the appropriate place for most medical services and coordination of care. We hope to have PCP involvement in the care plan, most specifically in the development of goals with the family. Further, we have a dietician on the team who is available to assist PCPs in the nutritional care of their patients and we welcome phone calls from the PCPs.
Any questions about communication with the hospital can be directed to Lee Budin, MD, at Lee.Budin@NationwideChildrens.org, William Long, MD, at William.Long@NationwideChildrens.org or Bruce Meyer, MD, at Bruce.Meyer@NationwideChildrens.org. They can also be reached at (614)722-4550.