Chronic Pediatric Patient Definition

From Guide to YKHC Medical Practices

We are often asked what defines a Chronic Pediatric Patient.

There are a few absolute criteria and then some softer calls.

  1. Premies delivered less than 35 wks. These patients are followed until they are 1-2 years of age or their prematurity related issues have resolved
  2. Pediatric patients that are followed by a pediatric subspecialty such as neurology, cardiology, endocrinology, etc. Peds does not need to follow patients seen by the regular ENT, ortho, Dermatology, Behavioral Health or surgery. We will follow a complicated ortho issue such as SCFE or Hip dysplasia until the problem is resolved.
  3. Pediatric patients that require close pediatric care management and village RMT follow up EX: a 2 month old with a first RSV infection admission will inevitably have recurrent lung issues and wheezing until they are 2-3 years old; these patients are usually best managed by the pediatricians with the health aides in the village and when seen in Bethel.
  4. Any patient that has had recent serious illness such as respiratory failure, meningitis with sequela, osteomyelitis or other pediatric orthopedic issues that require close follow up.
  5. Any infant or child that a provider, in collaboration with a pediatrician, feels warrants peds only care and care management.

Once a pediatric patient has been added to the CPP registry, they are seen in clinic by the pediatricians (unless none is available), admitted to the peds hospital service, managed by the pediatricians and our peds care managers and the health aides report all RMT to the peds service through Chronic Peds RMT.

CPP patients are assigned a primary outpatient pediatrician who is designated by village. The goal is to have the assigned pediatrician be responsible for adding and taking CPP patients off the registry as appropriate, seeing their own CPP patient’s in clinic and be responsible for medication refills, specialty care follow up, updating problem lists, village visits etc.. In reality, we do not have the staffing depth to do this …so we all do this with the CMs help.

Making a patient CPP

This should only be done by experienced YK pediatric providers. To add a patient to the CPP registry create a CPP Raven banner. Update the problem list with information as to why the patient was made CPP and pertinent follow up/care plans. If the patient is CPP for a problem that will or might resolve, make a note of this (ie CPP until hip dysplasia is resolved or until ECHO and murmur evaluation is complete etc.) NOTE: There is a custom education handout in RAVEN for a child who becomes CPP.

CPP patients will stay with peds until they are 18, they stop seeing a pediatric subspecialist or they are graduated from the registry. Older, complicated CPP kids must be formally transitioned to the family medicine service. Start transitioning early enough that they can visit adult specialist in Anchorage before they are 18 so that they can travel with a family member and have medicaid cover the travel.

CPP kids can and should be graduated as they get older and their chronic issues resolve. Be sure to make a note in the problem list that the patient has been graduated and make sure the family knows. NOTE: There is a CPP graduation certificate available in the peds folder and in RAVEN custom patient education.

Removing a patient from CPP Registry

This can and should be done by anyone with time to review a chart and make this determination. When a CPP patient has outgrown their reason to be CPP (ie no longer have a need for specialty care, close peds care management or are now relatively well) they can be graduated ☺. You can ask the CHA or a CM to let the family know that, on review of their recent history, they are well enough to be graduated from the CPP list.

How to Add and Remove CPP RAVEN banners

This should only be done by an experienced pediatric provider

Problem List: A quick method of communicating to other providers taking care of patient

see Updating Problem Lists for more information

When you make a patient CPP, put the reason/diagnoses for adding the patient and any pertinent notes. It is difficult and time consuming to look for and locate important patient documentation in encounter, RMT, multimedia and communication attachments when time is limited or in an emergency.

Looking at the Problem list and notes is MUCH faster. Comments can be added in the notes section of a problem to convey brief important care management information as things listed below.

If we work on keeping our problem lists updated by adding, modifying, resolving and inactivating problems we will improve continuity of care and save each other a lot of time trying to piece together care plans etc.

NOTE: For longer Care Plans and Individual Patient Protocols, put an alert note in RAVEN. Reference that note or any updated/new alert notes, by date, in the appropriate problem's comments. Writing a good note is great, but it is difficult to take the time to look through all the documentation to find a note that has the good details that you might need in a hurry.

Transition of Care

  1. Start transition of care as early as possible, but no later than 17 years of age. This will ensure the patient still has Medicaid coverage for themselves and their parent/guardian to fly with them to Bethel and Anchorage for appointments with adult Bethel providers and specialists.
  2. For complex pediatric patients identified as needing to transition to adult care-pediatric and adult medicine case managers find an accepting IM or FM provider for the patient and make an initial appointment with that provider. Ideally, the initial appointment is scheduled with an outpatient pediatrician followed by an in-person handoff to the adult provider.
  3. Clinic pharmacist reviews medications for transition from pediatric to adult medications/doses.
  4. Pediatrician writes a transition of care summary on an alert note in the patient’s chart. This note should be forwarded to the accepting adult medicine provider for review prior to the appointment.
  5. Pediatrician updates the Problem List and may reference the transition of care summary alert note (with date) in the comments.
  6. Pediatric and adult providers and case managers should document that the patient and family are aware of the transition process and that they demonstrate an understanding of diagnoses and care plans.
  7. When transition is complete (usually by age 18), pediatrician removes the CPP alert from the patient banner.
  8. If the patient is still seeing a pediatric specialist after 18 years of age, the accepting adult provider can communicate with the pediatric specialist directly and encourage transition to adult specialist.
  9. If the patient requires continued guardianship after turning 18 years old, help current guardians start the petition for guardianship process by completing this form as soon as possible. (more information can be found on the Alaska Public Courts Website.)
  10. Pediatricians and pediatric case managers will remain available for consultations and assistance throughout transition of care process.
  11. Resource: Got Transition (federally funded national resource center on health care transition (HCT))

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