Pediatric Complex Care Plan Adoption across the Continuum

Purpose: The pediatric complex care plan was created in the electronic medical record (EMR) to provide a centralized, concise location for the care team to document and easily access critical patient care planning information. The complex care plan is personalized for each patient and easily accessible at any time by the care team. Care instructions can be shared with patients and families through an after-visit summary that can be printed or viewed in the online patient portal.

Description: Care plans are an evidence-based strategy to improve communication and collaboration in the management of complex patients. Pediatric ambulatory care clinic nurses in our organization had difficulty locating critical care plan information for patients in the electronic medical record (EMR) related to nutrition, equipment, supplies, and therapies. Nurses documented care plan information in various locations within the EMR including in specialty notes that may or may not be viewable by other team members. Not having a standard easily accessible care plan created productivity challenges as nurses searched frequently for information and could potentially delay care.

In collaboration with informatics colleagues, a team of registered nurses, physicians, advanced practice registered nurses, case managers, and dieticians provided design input for a comprehensive complex care plan. The goal of the project was to increase the percent of pediatric complex care clinic patients with an updated care plan in the EMR to 80%.

Evaluation/outcome: The care plan was implemented in the pediatric complex care clinic in January 2020. By June 2020, approximately 70% of patients had a care plan present in their chart at the time of the visit. However, the number of patient care plans shared via the online patient portal was only 30%. Over the next 2 years, efforts focused on implementing the plan throughout our pediatric primary care and specialty clinics as well as spreading adoption to our inpatient areas to support patient care across the continuum.

Adoption of the pediatric complex care plan has grown, and today over 90% of complex patients have a care plan completed in the EMR. Next steps include further spread and adoption throughout surgical services and continued improvement of online portal access.