Care management for children with medical complexity: Patient characteristics, process improvement, and impact on satisfaction

Hannah Jacob MS, Reyna Lindert RN BSN PhD, Kayla Erspamer BA, Reem Hasan MD PhD


BACKGROUND: We created a nurse care management (NCM) program in an academic general pediatrics clinic with the goal of improving communication and increasing satisfaction among caregivers of children with medical complexity. All nurses in the clinic participated in delivering care management services; there was no specific funding for this work. Standard work processes were created for identification of patients, enrollment, creation of a care plan, pre-visit call scripts, and NCM co-visits. Pre- and post-intervention surveys evaluating needs, services provided, and satisfaction were completed by caregivers of 24 patients.  

OUTCOMES: Before intervention, 83% of caregivers reported that increased contact with the clinic would be beneficial. Within six months, we showed a 71% increase in the caregivers who reported that at least one nurse in the clinic knew their child’s health history. We found a 51% increase in reports of adequate assistance in acquiring special medical equipment. 48% noted that nurses definitely knew important information about their child’s care needs and care received from other providers, an increase from 4% initially. Caregiver knowledge of how to contact a nurse when they needed help or had a question increased by 39%.  

CONCLUSION: Our NCM model supports improved care coordination and caregiver perceptions of quality of care received. 

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