Introduction
Children with neurologic disease often are afflicted with issues affecting multiple organ systems and thereby require the care of multiple subspecialists and other allied health professionals. The complexity of these patient’s care requires special coordination often superseding the ability of the conventional practice of a primary care physician. The Complex Care Clinic at UW assists these patients who require multidisciplinary care by coordinating their care across multiple specialties. A solid understanding of the complexity of these patients’ care is important for child neurology residents to appreciate. The Complex Care elective allows for an immersive look into the care and coordination of care of children with medical complexity.
Schedule
The schedule for this inpatient and outpatient elective will be determined in the weeks preceding the rotation. Participation in intake visits at complex care clinic are an important learning experience. Rounding with the inpatient team on hospitalized complex care patients also takes place on an ad hoc basis. Attendance at the Complex Care Team Meeting on Thursday morning is expected.
Patient Care
Goals
Residents must demonstrate the ability to provide family centered patient care that is developmentally and age appropriate, compassionate, and effective for treatment of neurological problems and the promotion of health for patients in the AFCH complex care program. The role of ‘goals of care’ and complex care coordination should frame the understanding of care delivery for these patients.
Objectives
Demonstrate ability to efficiently collect history and physicals from new and established patients with neurologic disease both in the complex care clinic and established patients who are hospitalized.
Demonstrate an ability to participate in ‘goals of care’ conversation and recognize their importance in this patient population.
Apply learned methods of care coordination and recognize the barriers to care in patients with numerous medical needs.
Medical knowledge
Goals
To enhance knowledge of ethical issues regarding children with medical complexity.
Learn more about the community resources for children and youths with special health care needs, including Durable Medical Equipment, and home health care.
Objectives
Participate in discussions related to the ethical challenges of patients with complex care needs.
Identify patients with neurologic disorders who would benefit from available community resources.
Interpersonal Communication
Goals
Gain proficiency writing comprehensive care plans and crisis plans for patients with complex medical needs.
Communicate with a large network of providers all aiming to treat/manage patients with complex medical needs.
Objectives
Interface with providers in other subspecialties both in the outpatient and inpatient setting to arrive at a treatment path for complex care patients.
Create crisis plans and comprehensive care plans for complex care patients.
Practice-Based Learning and Improvement
Goals
Identify opportunities for improvement in the delivery and quality of patient care for those with complex medical needs.
Objectives
Review learning and improvement goals through frequent feedback from staff physicians working with them. Incorporate all available learning sources, including information technology to optimize their learning of all aspects of complex care.
Professionalism
Goals
Residents will demonstrate ongoing self-education and habits of life-long learning.
Objectives
Residents will maintain the highest standards of professionalism, especially in interactions with patients and complex care clinic faculty and staff. The resident will be responsible for tracking duty hours and reporting them to the supervisory attending.
Systems-Based Practice
Goals
Residents will recognize that they are part of a multidisciplinary team and the complexity required to coordinate care across multiple subspecialties.
Objectives
Identify barriers to efficient care delivery for patients with neurologic disease requiring multiple subspecialty care and arrive at mechanisms to coordinate avoid interruption of care.
