A Unique Approach to Care Coordination for A Pediatric Prosthetic Population

Cathy Moniaci, RN MS; Kim Ramey, PT; Joan Liberatore, OTR; David Eby, CO

Shriners Hospitals for Children in Houston is a pediatric orthopedic hospital providing care at no cost to children living throughout Texas and northern Mexico. With the growth of managed Medicaid in Texas, the hospital needed to develop new alliances to continue to reach its target population and to coordinate care to provide services not directly available in our hospital. This was accomplished through the implementation of Care Coordination. Care Coordination is a process/ program that was started in the Shriners Hospital-Houston in January of 2000. The goals of care coordination were to:

  1. create a family and patient centered environment and care coordination culture,
  2. maximize efficiency and effectiveness of patient care operations,
  3. Support care coordination at every department and functional level of the hospital.
  4. create a seamless continuum of care.

Often, so many people/disciplines interact with the patient and each one needs to know what the other is doing. That does not always occur on a consistent basis, so a major emphasis was placed on this initiative of care coordination. The hospital staff planned the care rather than react to patient needs at the time of visit.

At first, specific patient populations were targeted and the initial plan included the prosthetic/amputee patients. The traditional case management model was utilized, which was nurse driven. At the Houston Hospital, we started our care coordination team by combining the skills of both nurses and social workers. The development of the process needed to be budget neutral, so an evaluation of the existing staff was completed. This directly related back to the initial goal of efficiency with the process.

A gap in the coordination of services was quickly identified, specifically in the area of rehabilitation and physical/occupational therapy. Nurses and social workers were not trained to be able to identify specific issues in those areas.

Man with leg prosthesis

The prosthetic population of the Houston Hospital has several specific needs unique to our hospital. First of all, the prosthetics are outsourced. That service is not provided in the hospital. A local company makes the prostheses, attend the clinics, and then the patients are sent to them for the fittings, measurements and any adjustments that are needed.

Since the service area of the Houston Hospital includes patients from the northern part of Mexico, transportation has a huge impact on the patient care. There are Shrine Temples located throughout the state that often can assist with these needs. Sometimes patients have their own transportation, but just as often, bus tickets are provided by the hospital to get them to Houston to the clinic.

The model developed for care coordination of the prosthetic patient combines the efforts of both the therapist staff and the orthotics staff to coordinate the care of the patient. The patient becomes the focal point of the whole model, rather than having all disciplines interacting with the patients at only certain points of their care. The information support / computerized documentation system keeps the whole model together. In the effort to have information available to all disciplines, the computer system became vital to the success of the care coordination program.

Unlike the traditional model that was used initially, the model used for the prosthetic patients has the therapist as the one directing the overall care of the patient. The nurse and social worker are now on the periphery of care and are utilized on an as needed basis. In the Houston created model at Shriners Hospital - Houston, the physical therapist is the overall coordinator, responsible for the coordination of the total population. That includes clinic visits, telephone calls, therapy needs and interactions with the prosthetists. The therapist also personally works with some of the lower extremity patients as the physical therapist. An occupational therapist is the care coordinator for the upper extremity patients.

Obviously, the therapists have been taken out of their comfort zone to help care for these children. The job description was changed to reflect the new roles and responsibilities of the therapist care coordinators, that were developed by the care coordinators themselves.

The care coordinators are required to be in clinic when one of their patients is there, which has led to more time in the outpatient department for the therapists. This also means screening charts in preparation for that clinic visit. Telephone calls and any communication issues with patients between visits became the responsibility of the therapists. There were still nursing issues that could only be addressed by nursing, such as pre-op teaching and possibly some wound issues. It is the responsibility of the care coordinators to notify the nursing staff as these issues develop. The care coordinator is responsible for the preparation of the patient for an inpatient rehab admission, as this is their area of expertise. After every clinic, the care coordinators meet with the prosthetics company to assure that prescriptions and plans of care for each patient are concise and accurate.

Clinicians discussing

Since one of the new responsibilities of the care coordinators was the screening of charts and the ability to communicate with other hospital and outside disciplines, the access to information regarding the patient became crucial. In addition, with multiple responsibilities, the amount of time that it takes to get the information needs to be short.

The Information Systems Department in conjunction with the hospital staff developed a screening tool that gave all of the care coordinators access to a summarized medical history and plan of care. This screening tool informs of past patient history, upcoming clinic visits, a work order history and work orders that need to be completed for the upcoming clinics. This tool has decreased the amount of time it takes to screen charts by approximately 50% and often, with this tool, complete chart review is not necessary prior to clinic.

As the care coordinators worked more closely with the patients, a "needy" patient population was identified. The patients from the Southern Texas border and Northern Mexico continued to have transportation issues and follow up visits to the prosthetic company became nearly impossible. The Houston Hospital has an outreach clinic once a quarter that is held at a shrine club and is located down on the southern border of Texas. A second day was added to that clinic to care specifically for the prosthetic patients. The Shrine physicians as well as the care coordinators and orthotists are available to see the patients and address their needs. In order to provide access to a prosthetist, a company from Corpus Christi (which is only about 2 hours away from the Mexico border)is utilized. The patients are then able to make the follow up visits (which are held in that same clinic) and the transportation issue is somewhat resolved. The clinic is held near the Mexican border, so there are more Spanish speaking translators and the language barrier is now less of a limiting factor.

Have we made a difference? Some of the very positive outcomes include:

  • An increase in patient satisfaction, which has equated to a decrease in patient complaints. The patients/families are talking to the right person, initially to get the information they want and need.
  • Expanded services: a portion of the patients now have access to the prosthetist when they need them and they are closer to their home.
  • The therapists have learned and implemented new skills in patient care. They have more control and responsibility for the complete care of a finite number of patients. Additionally, they have improved their Spanish skills considerably.

Overall, coordinating these patients involves all disciplines having a more active and involved role in patient care. The orthotists are involved with the care up front and have input into the orders that will be generated for that patient. The hospital staff has become proactive rather than reactive. The change of focus to multidiscipli-nary coordination of care utilizes the outstanding expertise that is available at the Houston Shrine Hospital.

Authors Address:

Cathy Moniaci
Shriners Hospital for Children
Houston, TX