Team assists families in getting help they need

Goal is to find care coordination for every child

When a child is referred to the special needs program at the Children’s Hospital of Wisconsin, a multidisciplinary team assesses the case and decides where the family can get the help it needs. Children’s Hospital is a 222-bed tertiary care facility with multiple specialty clinics — and a teaching hospital affiliated with Medical College of Wisconsin in Milwaukee.

"One of our goals is to find appropriate care coordination experts for every child who is referred to the program, but we do look carefully at which children we can manage with our current resources," says Jeanne Musolf, MS, RN, CCM, manager of case management at the hospital.

Formalized referral system

The hospital has set up a formalized referral system and a dedicated telephone line for call-in referrals for the special needs patients. Referrals come from physicians in the hospital’s specialty clinics, pediatricians, inpatient case managers, parents, and community agencies.

"When we get a referral, we gather as much information as we can about the child, his or her diagnoses, how many and what physicians he or she sees, and

what the issues are for the family, whether it’s coordination of care, financial issues, problems helping the school understand the needs of the child, or community resource needs," says Deb Jablonski, RN, CCM, special needs case manager.

The multidisciplinary team for special needs children includes the nurse-case managers, an advanced practice nurse, a representative from the hospital’s Special Needs Family Center, a social worker, a rehabilitation physician, and the hospital’s special needs physician, who is a pediatric specialist and the medical director for the program.

The team meets weekly, discusses the referred cases, and decides who in the community can best serve the family.

"Sometimes, they don’t need a lot. They may just need to be connected to a community agency that can help with their concerns," Jablonski says.

Because of the program’s limited resources, the team determines when it is appropriate to refer families to other organizations that can help coordinate their child’s care.

For instance, if a child lives in a county with a public health nurse who has expertise in managing medically complex children, the team may refer the family to him or her.

Families may be referred to agencies such as United Cerebral Palsy, which provide care coordination in the community.

If a family is referred because most of the problems are psychosocial, the team refers them to a hospital social worker who is most appropriate to assist the family in their child’s care.

Those who are medically complex with multiple physicians and health care coordination issues are assigned to a case manager.

"First and foremost, we want to be sure that each family referred has a contact for care coordination. Additionally, maintaining reasonable caseloads for each case manager assures that they will be able to fully assist the families with their multiple needs," Musolf says.

Some children and families only need short-term help, such as helping the child through a chronic illness or surgery.

"Children with complex, chronic illnesses often have periods of relative stability which may be interrupted by an acute illness or transition issues. The case manager’s involvement varies according to the needs of the child and family. Ultimately, case managers work to empower parents to navigate the health care system and advocate for their child," Jablonski says.