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Service Delivery Innovation Profile

Hospital-Based Day Treatment Program Provides Family-Centered Services to Children With Chronic Illnesses and Emotional Issues as an Alternative to Outpatient and Inpatient Care


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Snapshot

Summary

The Hasbro Children’s Partial Hospital Program—a collaborative program of the departments of pediatrics and child psychiatry at the Alpert Medical School at Brown University—is a medical treatment day program for children ages 6 to 18 years old who have chronic medical illnesses and emotional issues. Located in the hospital with full access to all of the hospital’s services and resources, the program uses a family systems approach to treatment and makes parents an integral part of the treatment team. A long-term followup study has demonstrated sustained positive outcomes of treatment on several measures, including quality of life, emotional symptoms, and family beliefs about illness.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including quality of life, emotional symptoms, and family beliefs about illness.
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Developing Organizations

Hasbro Children's Hospital
Alpert Medical School at Brown Universityend do

Date First Implemented

1998
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Patient Population

Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children; Co-occuring disorders; Mentally illend pp

Problem Addressed

Although recent advances in medicine have resulted in more effective treatments for some children with acute and chronic illnesses, other children, particularly those with emotional issues, have received little if any benefit from new technologies and approaches to care. Except for brief, crisis-oriented inpatient hospitalizations, these children and their families often “fall through the cracks” of conventional pediatric care. They are not sick enough by today’s standards for inpatient care, but their outpatient treatment generally has been unsuccessful. Key aspects of the problem are detailed below:
  • Complications due to emotional issues: Emotional factors often impede the delivery of effective medical care, while the presence of medical illness can be a barrier to the provision of effective psychiatric treatment. Chronically ill children with concomitant emotional illness often do not adhere to treatment regimens because of anxiety or depressive disorders, lack of knowledge, or family conflicts. Family life often revolves around the child’s illness, creating stress for the entire family.1
  • Difficulty in diagnosing problems: Some children have vague or intermittent symptoms that make diagnosis difficult. Closely supervised medical observation may allow for a more definitive diagnosis.1
  • Net result is missed school, frequent hospitalizations: Many children with chronic physical and emotional illness miss a substantial amount of school because of their poorly controlled symptoms.1 In addition, without access to an intermediate level of care, children who cannot be successfully cared for in an outpatient setting often end up requiring costly inpatient care.

What They Did

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Description of the Innovative Activity

Chronically ill children and adolescents who also have emotional issues attend the day-treatment program as an alternative to traditional outpatient or inpatient care. The program, in which a multidisciplinary treatment team works to stabilize both medical and psychiatric symptoms, uses a family systems approach to treat the whole child and his or her family. The children receive treatment 5 days a week in the hospital during the day, for an average of 18 days, returning home in the evening and on weekends. This approach reinforces the partnership between the parents and program staff while still allowing children and parents to learn to manage the child’s symptoms independently. Key elements of the program include the following:
  • Eligibility: Children are eligible if they do not require 24-hour medical management in an inpatient setting, if they have parents who are able to care for them at home, and if their previous therapies, which typically focused only on their medical problems, have been unsuccessful (i.e., they have failed outpatient treatment). Common medical conditions include diabetes, asthma, pain syndromes, gastrointestinal disorders, and eating disorders; common psychiatric/emotional conditions include depressive disorders and anxiety issues.
  • Access to hospital staff and resources: The program is located in the children’s hospital, which provides access to all of the hospital’s resources, including treatment, diagnostic testing, imaging, and staff.
  • Multidisciplinary treatment team: Beginning on the first day of admission, nurses, child psychiatrists, child psychologists, pediatricians, and other specialists (e.g., nutritionists) meet with parents and children. The involvement of all these individuals in the child’s treatment from the beginning sets the expectation that everyone, including the family, will collaborate as members of the primary care team.
  • Structured days: The program operates from 7:30 a.m. to 3 p.m. Monday through Friday. The day is designed to be the approximate length of a school day (which serves as good practice for going back to school). Each day is structured as follows:
    • Medical evaluation: At admission and each morning, a pediatric nurse performs a medical evaluation of the patient that is symptom specific and includes appropriate medical care such as the administration of insulin for diabetes.
    • School: Patients attend an hour and a half of school, where a qualified teacher helps them to stay abreast of their course work.
    • Group therapy: Group therapy sessions are held to give patients an opportunity to address their emotional needs.
    • Socialization: Afternoon activity groups facilitate socialization among patients and families.
  • Medical update given to parents: The daily medical evaluation is given to parents at the end of each day so that they know how to continue treatment at home in the evening and on weekends.
  • Collaboration: Pediatric and mental health staff collaborate throughout the day. Program staff also collaborate with the family, schools, and other community providers. For example, staff contact each child’s school for assignments and help the children keep up with schoolwork as much as possible.
  • Emphasis on lifestyle choices: The program staff emphasizes making healthy choices related to eating, exercise, emotional expression, socialization, and attitudes toward school.
  • Family involvement: Many aspects of the program are designed to incorporate the family in the care of the child and to support and empower the family in playing this role. Family meetings and family therapy are regularly used to address needs and to get parents and other family members to commit to being involved in the child’s care on a daily basis.

Context of the Innovation

Hasbro Children’s Hospital is an 87-bed hospital that serves as the pediatric division of Rhode Island Hospital; both are teaching hospitals for the Alpert School of Medicine at Brown University. The Hasbro Children’s Partial Hospital Program is a collaborative program of the departments of pediatrics and child psychiatry at the Alpert School of Medicine. The children’s hospital staff had long been interested in the interface between emotional and physical factors in children’s illness, and wanted to create a low-cost day treatment program that could teach patients and their families to manage both without the need for an expensive inpatient stay.

Did It Work?

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Results

The program conducted a 1-year followup study on 89 children that evaluated pre- and post-implementation quality of life, emotional symptoms, and family beliefs about illness. (More than 1,500 children have been treated in the program since its inception in 1998.) Results showed significant improvement in all areas.
  • Improved quality of life: Scores from the Child Health Questionnaire demonstrated statistically significant improvement in the following areas: physical health, psychosocial well-being, and family activities.
  • More positive family beliefs about illness: Results from a questionnaire that probed the degree to which the illness controls family life and the life of the child found statistically significant improvement in the following areas after admission: satisfaction with the child's, parents', and family's life; illness controlling the child's, parents', and family's life; hopefulness that the child's illness will be controlled in 6 months; child and parents' understanding of the illness; and child and parents' control over the illness.
  • Lower costs: Children receive many, if not all, of the benefits of inpatient treatment without the added cost of staying in the hospital overnight (a partial hospital day costs approximately one-third the cost of an inpatient day).

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key metrics, including quality of life, emotional symptoms, and family beliefs about illness.

How They Did It

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Planning and Development Process

The planning and development process included the following activities:
  • Stakeholder meetings: During the year-long planning stages of the program, numerous meetings were held with third-party payers, hospital administration, and providers of specialty pediatric care to convince stakeholders of the benefit of the program for patients.
  • Building referral sources: Program staff met with school psychologists, school nurses, pediatric practices, and families in the community to introduce them to the program and encourage referrals. Staff work continually to maintain referral sources.
  • Staffing and training: The hospital’s leadership looked for staff who believed in the interaction between physical and emotional illness and in the effectiveness of treating both simultaneously. The program started by using existing staff and as it has grown, more additional staff have been hired. New staff received special training in the treatment model.
  • Development of questionnaire: Program developers are currently creating an “Illness Beliefs Questionnaire.”

Resources Used and Skills Needed

  • Staffing: In addition to two codirectors (a pediatrician and a child psychiatrist), the program requires 16 full-time equivalent (FTE) staff to treat an average of 14.5 patients at a time (nine adolescents and five children), including 1.75 pediatricians, 5.0 pediatric nurses, 1.75 child psychiatrists, 3.25 child psychologists, 1.5 social workers (who also does intake and case management), 2 half-time teacher, 1.0 nutritionist, and 1.0 diet technician (Updated June 2013). 
  • Costs: The costs of the program consist of the salary and benefits costs of the above staff members.
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Funding Sources

Most major insurers provide reimbursement for the program, which they view as a low-cost alternative to inpatient care. This reimbursement covers operational expenses.

The hospital received a grant from the National Institutes of Health to develop the “Illness Beliefs Questionnaire.”end fs

Adoption Considerations

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Getting Started with This Innovation

  • Secure insurance reimbursement: Meet with insurance company representatives to secure their commitment to reimburse for program services, since third-party reimbursement is critical to program development and ongoing operations.
  • Obtain leadership support: Seek leadership support for allocating the required staff and space for the program.
  • Conduct a pilot test: Consider testing the program’s effectiveness in a small, year-long pilot program before expanding it.

Sustaining This Innovation

  • Maintain insurer relationships: Visit with insurers regularly to explain and reinforce the benefits of the program. Insurers often do not understand how to categorize claims from this program because it provides a combination of medical and psychiatric treatment.
  • Empower families: Empower the family to manage the child’s symptoms, and encourage the active, ongoing participation of parents in the child’s treatment. Often parents think that their child’s illness has taken control away from the family, but emphasize that successful treatment during the day depends on parents’ continuing the treatment at night (and vice versa).

More Information

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Contact the Innovator

Michelle Rickerby, MD
Hasbro Children’s Hospital
593 Eddy St.
Providence, RI 02912
Phone: (401) 444-8638
Fax: (401) 444-2085
E-mail: mrickerby@lifespan .org

Innovator Disclosures

Dr. Rickerby reported having no financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Roesler TA, Rickerby ML, Nassau JH, et al. Treating a high risk population: a collaboration of child psychiatry and pediatrics. Med Health R I. 2002 Sep;85(9):265-8. [PubMed]

Footnotes

1 Roesler TA, Rickerby ML, Nassau JH, et al. Treating a high risk population: a collaboration of child psychiatry and pediatrics. Med Health R I. 2002 Sep;85(9):265-8. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 24, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: June 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
The multidisciplinary care offered by the Hasbro Children’s Partial Hospital Program at the Brown University Alpert Medical School helped 15-year-old Jen and her family  address her health problems so she could return to school and thrive. Diagnosed with diabetes when she was a toddler, Jen was having difficulty managing her...

Read more