CHOP and Insurer Collaborate for Complex Patients

As the inpatient care coordinator for children with complex medical needs who are seen at the Nicholas and Athena Karabots Pediatric Care Center, Suzanne kept all of a child’s care providers in the loop on hospitalizations and discharges. Things can get complicated for families whose child needs to see several different doctors for different ongoing medical issues or is frequently hospitalized. It’s easy for them to get overwhelmed.

Children’s Hospital of Philadelphia is working to make things easier for families. Together, CHOP and Keystone First, Pennsylvania's largest Medicaid managed care health plan, created an innovative way to support these families with a partnership called Karabots-Keystone Cares (K2C).

More than 500 patients who call the Nicholas and Athena Karabots Pediatric Care Center their medical home get extra attention from a team of K2C care coordinators. They help families navigate the health system by lining up specialty care appointments, remind parents when their child is due for an appointment or well visit, follow up with the family after inpatient stays or Emergency Department visits, and connect families with community supports.

The eight care coordinators are the cornerstones to the program, but they are supported by a team of nurses, doctors, community health workers, a social worker and an office administrator.

One important feature of the program is an inpatient care coordinator, who keeps tabs on all K2C patients who are in the hospital or Emergency Department. Her role is to ensure that all patients’ physicians, including their primary care doctors at Karabots, are aware the child is at CHOP. She also works with families to ensure a smooth transition home at discharge.

For some patients, going home may mean arranging for home nursing care, delivery of medical equipment or training parents on how to give medications or treatments. The inpatient care coordinator works with the patient’s inpatient care team, the home care team and the family to ensure all the necessary pieces are in place to support the child upon discharge.

She also shares pertinent information with the family’s assigned care coordinator at Karabots, who will help the family schedule necessary follow-up appointments to keep recovery on track.

All this extra attention is working.

In the first 15 months of the program, the more than 500 medically complex children enrolled in K2C were hospitalized about 23 percent less frequently compared to before they were enrolled. They went to the Emergency Department 15 percent less often, too. In part due to fewer hospitalizations, average healthcare charges for these patients dropped approximately 35 percent.

It’s a combination of the big things — like making sure families have appropriate home care services to support the child and transportation to pediatric and specialty care appointments — and the small things — like making sure a child gets the annual flu vaccine, immunizations and checkups — that help the child stay well.

What is a care coordinator?

A care coordinator advocates for patients with complex needs while in the hospital and eases their transition after discharge. Several care coordinators are funded by philanthropy, making it possible for CHOP to provide the best patient and family experience.