OPIP will facilitate Kaiser Permanente Northwest (KPNW) on the development of a Pediatric Care Together© (PCT) program in order to summarize learnings related to: 1) use of KPNW-level medical and social complexity data to identify children with health complexity for team-based care; and 2) tools for administering a pediatric team-based care program.
Over the last five years, OPIP received two grants supporting consultation and support to KPNW in their efforts to build, pilot, and evaluate a complex health management program focused on children with health complexity. This funding included a subcontract from the state’s Title V agency (the Oregon Center for Children and Youth with Special Health Needs) Systems of Services for CYSHCN grant and the Lucile Packard Children’s Health Foundation.
Through these efforts, OPIP provided technical assistance to KPNW to support the development of their complex care management program (called Pediatric Care Together© or PCT) by supplying references, conceptualizing the health complexity methods to apply, and creating tools for KPNW consideration. The underlying construct is based on the concept of using health complexity information to identify patients who may benefit from supplemental supports often not provided by a conventional medical home team or by an exceptional needs care coordination team. This complex care management program would also identify the right, best team members to provide these supports. In addition, the assigned team supporting these patients would need to perform detailed assessments of the children and families in order to determine the levels of support they would benefit from, figure out ways to share and track the plan, as well as evaluate the effectiveness of the program.
Within KPNW, these elements and tools were explored, refined, customized, and built by KPNW leadership and the PCT© Operations team. KPNW then piloted the model in one site, located at the Mt Scott pediatric clinic, and has subsequently spread the model to one other site. Joyce Liu, MD, the Medicaid Medical Director for Kaiser Permanente Northwest, has been the lead champion, advocate, and developer of the KPNW specific components of this model. Dr. Liu has also led efforts to share aspects of the model across other Kaiser Permanente regions.
Although every health system has unique features that necessitate individual considerations in building a complex care management program, the purpose of this summary report is to share learnings gathered through this joint effort between OPIP and KPNW. We believe there is much to learn from the process, and we describe and share these models and lessons in this summary.
Click here to read a Summary of the OPIP/KPNW Collaboration to Develop and Pilot the PCT Program.
- Figure 1: High-level Conceptual Framework and Design for PCT program
- Figure 2: KPNW System-level Social Complexity Data Available in Searchable Fields
- Figure 3: Health Complexity Categorical Variable
- Figure 4: Social Complexity Data Asked in Patient Surveys at Well Visits
- Figure 5: PCT Intensity Stratification
- Figure 6: PCT Model
- Figure 7: Longitudinal Plan of Care
- Figure 8: Proposed Evaluation Framework
Click here to review an overview of the Parent/Youth Completed Survey meant to operationalize the patient reported items within this section.