Follow-Up to Ensure Continuity of Care and Support Preventive Care

Abstract

Children with complex chronic conditions are a frail population requiring specialized and continuing care. Continuity of care of such children should be oriented to a comprehensive and tailored approach toward each individual. In pediatrics, continuity of care is associated to decreased emergency department visits, increased therapeutic adherence, and improved receipt of preventive screening. The healthcare services are generally poorly efficient in delivering continuity of care for chronic health conditions. The need for obtaining substantial improvements in care delivery for these children led to the creation of new models of care aimed at delivering a set of services provided by a defined team, assessment-driven, and designed to address the needs of patients and their family. Models of care can be divided into primary care-centered models, consultative- or co-management-centered models, and episode-based models. Integrated care should include health services as part of a whole system of prevention and care in both primary care and subspecialty units. An ideal care delivery system for children with medical complexity should ease parental financial, time, and emotional burdens through support strategies such as in-home care, access to respite facilities, increased financial resources, and adult mental and physical healthcare services. Ongoing research to develop standardized outcome measures and evaluate existing care delivery systems is essential to ensure the delivery of high-value care for children with complex conditions. Moreover, barriers faced by racial/ethnic minority groups or those of low socioeconomic status and poor health literacy should be addressed to avoid social disparities and poor access to care.