2024 Lightning Talk: Pediatric Complex Care Clinic – Dr Jennifer Balfour (in photo), South Island Facility Engagement Initiative Society
Identifying a new patient population
Dr Jennifer Balfour, a pediatrician from Victoria General Hospital, identified an important but poorly visible new pediatric patient population whose care is not easily accessible or coordinated in the health care system.
These children have no “one disease,” but a collection of issues as a result of extreme pre-maturity, genetic diseases, and the successes of intensive care. They can create technology dependence, frailty, multiple medical visits, and vulnerability to de-compensation.
Creating a proposal for a new service
Dr Balfour utilized South Island Facility Engagement funding to create a proposal to support service planning and a system to:
- Keep medically frail children close to home
- Coordinate complex care needs
- Raise the visibility of the “new” pediatric patient
- Ensure care of these children is sustainable for the practitioner and care teams
- Avoid duplication and streamline communication between care providers
- Reduce the amount of work for families supporting this patient population
Bringing the pieces together
Dr Balfour worked with a project manager to create a comprehensive proposal, vision, and care map showing patient touch points and intersections in the system. It illustrated the services needed, and how to meet them.
It identified what a care team could look like – including pediatric and other medical providers, a pivotal nurse role, a dietitian, pharmacist, social worker, and care coordinator. It also:
- Demonstrated how complex care issues can be addressed.
- Recommended how to improve relationships between hospitals and community services as children move through these environments.
- Raised the visibility of generalist care.
Lessons and success factors
- Create a clear project proposal that does “all the work” and aligns with health authority strategic goals.
- Resist pressure to silo care and service creation around having the “right disease.”
- Define the problem frequently, and use tangible communication methods.
- Utilize a project manager to approach a complex problem using health authority language, strategic priorities, and continue to press the work forward in light of competing demands and multiple stakeholders.
- Stay on course with persistence and passion.
Next steps include an engagement process to start taking steps towards achieving the services.
“While only making up less 1% of the pediatric population, these patients use up 30% of health care dollars [in this population] and are significant users of inpatient hospital beds and intersect with the health care community in multiple ways...Our goal is to keep medically frail children close to home… to coordinate their very complex care needs.” – Dr Jennifer Balfour
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