Care Transformation Center Blog

Three tips for simplifying care for medically complex children


Cabell Jonas and Yulan Egan

Children with complex medical issues and special health needs can be among the most challenging patients to effectively manage. Their care requires seamless coordination between providers, frequent appointments and follow-ups, and constant communication between providers and family members. These children are often covered by Medicaid, making it particularly difficult for providers to provide wraparound support under the limits of Medicaid’s low reimbursement rates.

To simplify care delivery for this vulnerable and high-risk population, some organizations are turning to modified medical homes.

Here are three tips from the Arkansas Children’s Hospital's Medical Home Clinic—a consistent site of care for high utilizers that saved nearly $15,000 per patient per year.



Three takeaways for every organization

1. Co-locate specialties and services to simplify patient care.
ACH's program highlights the importance of co-locating care services for the most complex patients. Having different subspecialties located in the same physical space saves time for the patient and caregivers, results in simplified and coordinated care plans, and may cut costs for providers.

When physical co-location is impossible, use IT systems to help centralize notes and activities to avoid duplication and unnecessary replication of care steps.

2. Implement a team-based approach to coordinate care plans.
Team-based care is essential for patients requiring services across a variety of specialties. Having all of a patient’s providers represented results in a clearer care plan. Providers will be less prone to duplication or error when they work together to make recommendations and provide treatment.

If bringing providers together is impossible, designate a central point of contact to coordinate providers and answer patient and caregiver questions.

3. Invest in outpatient coordination to decrease unnecessary inpatient costs.
Focusing on higher-quality and streamlined outpatient care can have a dramatic impact on inpatient costs and health outcomes.

While outpatient costs may rise slightly, any costs accrued in the outpatient side has the potential to be offset by savings on the inpatient side from both reduced length-of-stay as well as avoided unnecessary hospitalizations.

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