Article Title

Medically Complex Pediatric Patient Care Model: Coordinated Team-Based Care With Supporting Health Information Technology to Implement Best Practices and Address Care Gaps of Transitioning Age Patients and Family Caregivers

Publication Date



children with medical complexity, caregivers


Background/Aims: Medically complex pediatric patients have multiple severe chronic conditions consuming disproportionate health care resources. The top 1% of Geisinger’s pediatric population uses health care representing 20% of total costs. Nationally, their needs are largely underserved by current delivery systems as they involve multiple specialists and settings, are challenging to coordinate, and place a tremendous burden on family caregivers. Providing effective care for children with special health care needs (CSHCN) requires a system that is integrated, comprehensive, coordinated and family-centered to foster positive experiences between families and providers. Advancing integrated systems of care for CSHCN and their families is a national priority and reflected in the Healthy People goals. Geisinger has developed a new innovative approach to CSHCN starting with ages 15 and over: the Medically Complex Pediatric Patient (MCPP) care model. Its objective is to address patient and family caregiver needs along with drivers of poor quality and unnecessarily high costs of care. This approach includes: (1) a comprehensive care clinic with an enhanced professional care team to provide and coordinate health care supported by (2) care bundles for reliable delivery of best practices and (3) advanced health information technology using Geisinger’s patient portal and Web-based applications to efficiently document and facilitate timely care, planning, management and coordination and promote good communication between families and providers.

Methods: Development and implementation of the MCPP care model and an evaluation plan are occurring simultaneously. The evaluation plan begins with newly developed patient and family caregiver assessment questionnaires administered to all eligible families to collect baseline and postimplementation measures, with questions corresponding to multiple nationally validated surveys (National Survey of CSHCN, GAD-7, PHQ-9, Caregiver Strain Index).

Results: Survey results of approximately 300 families will establish intensity of caregiving needs, caregiver challenges and ability to meet needs effectively, service quality and gaps consistent with national measures including CSHCN core outcomes that facilitate integrated systems of care for CSHCN such as care coordination, partners in decision-making, and medical home to assess preimplementation gaps and postimplementation performance.

Discussion: Baseline results will be used to inform MCPP care model implementation and to assess its progress and performance over time consistent with national priorities.




March 30th, 2015


April 28th, 2015