St. Joseph’s Children’s Hospital Creates Clinic for Children with Complex Needs
In an average month, about 200 patients visit the Chronic Complex Clinic. Patients and their families report high levels of satisfaction for both the care they receive as well as the coordination of services outside the clinic. With the creation of the clinic, emergency room visits, hospitalizations, and total days in the hospital for this complex population have decreased.
The Chronic Complex Clinic (CCC) was born at St. Joseph’s Children’s Hospital (SJCH) in 2001 when a pediatric intensive care unit (ICU) physician recognized that many of the children with complex conditions were frequently admitted to the hospital, often unnecessarily, due to either uncoordinated care, or due to caregiver challenges when providing the care at home. Dr. Daniel Plasencia believed that the creation of a medical home for these children would provide better coordination of their care and in turn reduce hospital admissions. St. Joseph’s Children’s Hospital agreed, and committed to helping these medically complex patients and their families receive the care they need through the hospital’s Chronic Complex Clinic.
The Clinic is now a medical home that provides primary care services to more than 1,000 patients and families for children with multiple medical issues. Many of the children who once went to the emergency room now call the Chronic Complex Clinic their “medical home,” where they receive care tailored to their special needs.
The health needs of children with multiple medical issues can be complex, diﬃcult to coordinate and cumbersome for families. The Chronic Complex Clinic provides primary care services, coordinates specialty care services, addresses social and psychological concerns, and provides continuity of care during hospitalizations. In addition to a physician and nurse providing medical care in the clinic, the Chronic Complex Clinic is staﬀed by a full- time social worker and a part-time child life specialist. The social worker and child life specialist help patients and families navigate the health care system to receive the care they need. Caregivers coordinate family-centered programs, parent support groups and play groups. They work directly with children on coping mechanisms for procedures, keep them occupied while waiting for visits and help them through immunizations. The success of the Clinic lies in its commitment to reach beyond traditional medical care, providing families with “one stop shopping” for the resources and support they need to successfully manage their child’s overall health.
The Clinic is located in the Medical Arts Building of St. Joseph’s Hospital, co-located with many of the pediatric sub- specialists and rehabilitative services utilized by the families served by the clinic. The co-location of these services contributes to better communication between providers, as well as allowing families to schedule multiple appointments during the same visit. St. Joseph’s understands that transportation alone can be burdensome for families, and being able to see more than one provider or receive therapies on the same day as a primary care visit makes getting essential care easier for patients and their families.
In an average month, the Chronic Complex Clinic treats about 200 patients. Patients and their families report high levels of satisfaction for both the care they receive as well as the coordination of services outside the Clinic. With the creation of the clinic, the number of emergency room visits decreased from 83 to 53, hospitalizations decreased from 93 to 67, and the total days in the hospital for this complex population decreased from 607 days to 452 days.
The Chronic Complex Clinic accepts all patients, regardless of insurance coverage. St. Joseph’s Children’s Hospital supports this clinic as an extension of its mission to serve the community, and in 2012 spent over $500,000 to support the Clinic’s critical community service.
“Dr. Plasencia has had a long and distinguished career as a clinician, but what sets him apart and inspires me is that he has become a tireless advocate for the appropriate care for medically complex children, for which my family will be eternally grateful…children and families facing the challenges of coordinating the care of their medically complex child have the resources they need at St. joseph’s Children’s Hospital.”
-Claudine Caballero, parent of Elizabeth, born in 1994 and diagnosed six months late with Type I Spinal Muscular Atrophy.