Core Competencies

4.03 Healthcare Systems: Consultation and Co-management

Introduction

Pediatric hospitalists are often asked to offer clinical guidance, recommendations, or support to healthcare providers in managing children in a variety of contexts. These providers are usually adult providers or other pediatric subspecialists. There are two general models for this arrangement: consultation and co-management. Consultation generally refers to a paradigm in which the primary team requests input to manage a specific clinical problem or set of problems that would benefit from specific expertise. Co-management describes a model in which a patient requires ongoing care served via a partnership between the primary team and another specialty service. Consultation and co-management roles for pediatric hospitalists involve caring for medical and surgical patients. Many different models exist within these two broad categories. These models vary based on setting, local needs, or local pediatric expertise. Regardless of model, similar skills are required, especially involving communication and coordination of care. Pediatric hospitalists are in a unique position to improve care delivery and advocate for the needs of children within consultation and co-management roles.

Knowledge

Pediatric hospitalists should be able to:

  • Describe consultation and co-management models, including characteristics of local models.
  • Articulate the responsibilities typically defined by consultation and co-management models.
  • Review the importance of clear communication, multidisciplinary team engagement, and roles of different care providers within a consulting and co-management model.
  • Compare and contrast the value of verbal versus written agreements for consultation and co-management relationships and discuss their impact on patient safety.
  • Discuss the intent and impact of mandatory consultation for hospitalized children based on certain criteria, such as age or underlying condition, especially regarding patient safety and the role of pediatric hospitalists.
  • Recognize opportunities for pediatric consultation to offer recommendations for the whole child, attending to immunizations, dental care, and other preventative needs.
  • State examples where a one-time consultation may be appropriate.
  • Describe common failures in consultation and co-management, especially regarding handoffs, patient communication, documentation, billing, and others.
  • Summarize basic surgical conditions, indications for common surgical procedures, and list common complications of surgical procedures.
  • Describe the principles of preoperative and perioperative care, including roles for anesthesiologists, subspecialists, surgeons, and pediatric hospitalists.
  • Describe common pain management modalities, including medication and non-medication interventions, attending to potential side effects of medications including narcotics.
  • Compare and contrast billing procedures for consultation and co-management from billing as primary attending of record, with attention to the impact of billing by other providers.

Skills

Pediatric hospitalists should be able to:

  • Provide a timely and comprehensive evaluation of pediatric patients and pediatric-specific recommendations.
  • Demonstrate strong diagnostic and management skills in the care of hospitalized children, including those with medical complexity and common surgical conditions.
  • Communicate recommendations clearly and efficiently to other subspecialists and healthcare providers.
  • Diagnose complications of common surgical procedures, including features of clinical deterioration.
  • Communicate effectively with the primary team regarding complications or other declines in status and triage to a higher level of care as appropriate.
  • Identify and abate pediatric-specific patient risks due to age, underlying condition, local resources, or other factors.
  • Coordinate care and communicate clearly and effectively with patients, the family/caregivers, and all team members.
  • Demonstrate expertise in pain management, especially in the perioperative patient.
  • Describe principles of perioperative fluid management in the pediatric surgical patient.
  • Explain the pediatric hospitalist’s role in consultation and co-management with the patient and the family/caregivers.
  • Maintain clear, timely communication and documentation of clinical recommendations.
  • Place patient care orders when appropriate.
  • Educate trainees, including pediatric and surgical trainees, about models of consultation and co-management.
  • Create a comprehensive discharge plan in partnership with the primary team.

Attitudes

Pediatric hospitalists should be able to:

  • Exemplify responsible and accountable care of hospitalized children within the scope of the consultation and co-management relationship across differing clinical specialties.
  • Reflect on the importance of providing timely patient care, documentation of recommendations, and written orders as appropriate.
  • Realize the importance of communicating effectively with patients, the family/caregivers, subspecialists, and other healthcare providers.
  • Respect the contributions of all healthcare team members.
  • Recognize that gaps in knowledge and skills may adversely impact patient care and role model behaviors that promote patient safety and quality care.

Systems Organization and Improvement

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

  • Collaborate with other subspecialist leaders by providing input to improve consultation and co-management programs.
  • Identify opportunities to lead, coordinate, or participate in activities to enhance teamwork between healthcare professionals.
  • Lead, coordinate, or participate in identifying and managing aspects of consultation and co-management care that may be targets for quality improvement.
  • Collaborate with administrators and colleagues to optimize hospitalist value provided and assure practice is appropriately within the scope of the hospital medicine.
  • Lead, coordinate, or participate in the development of guidelines for consultation and co-management programs.

References

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