NRNP 6831 Week 10 Discussion Post Example

Week 10 Discussion: Initial Post

The Follow-Up Nobody Booked: Splitting Coordination Between a Complex Care Program and a Local Practice in Writing

Aria is a composite 12-year-old with Lennox-Gastaut syndrome, a gastrostomy, and scoliosis. She is enrolled in a complex care program at a children's hospital 70 miles away, which manages her seizure plan and specialty care, and she is also seen by a family practice near home for acute illness and well care. Last month she went to the local emergency department with a seizure cluster, was stabilized, and was sent home with instructions to follow up. The complex care program assumed the local practice would book the visit; the local practice assumed the program would. Nobody did, and her mother waited three weeks before calling.

The question this week is how far a primary care practitioner's share of coordination goes. Coordination is hard to assign as one word, so I used the AHRQ Care Coordination Measures Atlas, which breaks it into activities: establishing accountability, communicating, facilitating transitions, assessing needs and goals, creating a proactive plan of care, monitoring and following up, supporting self-management, and linking to community resources (McDonald et al., 2014). Once coordination is a list, it can be split.

Assigned to the complex care program: the proactive plan of care for her seizures, because the neurologists who write it are there; monitoring of specialty follow-up; and support for self-management of her seizure plan and gastrostomy, because the program's nurses taught it. Assigned to the local practice: facilitating transitions after any local emergency visit or admission, because the local hospital sends its reports there first and the practice is 10 minutes from the family; assessing needs and goals at well visits; and linking to community resources such as school services and respite, because the practice knows the local options. Shared, with the program as lead: communicating, through a shared plan both sides can open.

My position is that a primary care practitioner answers for the activities assigned in writing, plus a duty to flag any activity that appears and has not been assigned. The practitioner does not answer for everything, which no one can meet, and does not answer for nothing, which abandons the medical home premise of this course. The AAP care coordination framework calls for a written plan of care that states who is responsible for what across systems (Council on Children With Disabilities and Medical Home Implementation Project Advisory Committee, 2014), and the absence of that clarity is part of why these children's care fragments (Kuo et al., 2016). Under my split, the local emergency visit falls under facilitating transitions, so the local practice books the follow-up, and the missed visit would not have happened.

The written agreement would contain the activity list, the owner of each, the contact for each side, the time frame for a post-emergency follow-up (within 1 week), and a rule that any unassigned task is flagged to the program's coordinator the same day.

Reply to Nicole

Nicole, you argued that the medical home should own all coordination. I would test that against Aria's missed follow-up. Under your model, the local practice would have booked it, but would it also own her seizure plan changes made by neurology 70 miles away? If not, which activities would you hand back, and in writing?

Reply to James

James, I liked your idea of a shared care coordinator funded by both sides. In Aria's case, though, a shared coordinator could still have assumed the other side would call. Would your model have caught the missed follow-up without an explicit rule about who books visits after emergency care?

References

Council on Children With Disabilities and Medical Home Implementation Project Advisory Committee. (2014). Patient- and family-centered care coordination: A framework for integrating care for children and youth across multiple systems. Pediatrics, 133(5), e1451-e1460. https://doi.org/10.1542/peds.2014-0318

Kuo, D. Z., Houtrow, A. J., & Council on Children With Disabilities. (2016). Recognition and management of medical complexity. Pediatrics, 138(6), Article e20163021. https://doi.org/10.1542/peds.2016-3021

McDonald, K. M., Schultz, E., Albin, L., Pineda, N., Lonhart, J., Sundaram, V., Smith-Spangler, C., Brustrom, J., Malcolm, E., Rohn, L., & Davies, S. (2014). Care coordination measures atlas: Version 4 (AHRQ Publication No. 14-0037-EF). Agency for Healthcare Research and Quality.