ATS GUIDELINES Bundle

5 Table 1. Features of a Comanaged Medical Home for Children Requiring Chronic Invasive Ventilation in the Home e care would be family/patient centered. Recognition of patient/family preferences, social services availability, barriers to communication or medical provision is necessary. Medical Home provider oversight would be provided by a collaborative partnership between the generalist and pediatric pulmonologist, and other necessary subspecialists. Keeping in mind that many children requiring mechanical ventilation are equally dependent on subspecialists, such as neurologists, gastroenterologists, physical therapists, etc., this collaborative partnership depends on the situation and will require oversight from a specific provider most accessible to the family and identified as primarily accountable. is provider is frequently but not necessarily the primary care provider. e specific roles and responsibilities of each provider would be clearly delineated for each practitioner, all members of both teams, and the patient and family. In practice, a written summary of responsibilities will be provided to the team and family by a social worker or nurse or primary care provider outlining expectations and order of communication channels. e pulmonologist and team would be responsible for management of all pulmonary and related aspects of care. e generalist would be responsible for all aspects of primary care. e comanagement collaborative would decide and delineate responsibility for comprehensive assessment, coordination, and management of all other aspects of care. is includes access to medical care, transportation, family care and respite, access to nutritional needs, community resources, etc. A social worker or local public health resource may be crucial to assist the primary care provider. Pulmonologists, medical specialists, and their teams will be required to assist in coordination of complex care requirements and appointments to lessen the burden on the family. Much care can be delegated to the local primary caregivers with communication from the specialist teams. Effective communication tools would be used to ensure effective implementation of the comprehensive care plan, without redundancy or duplication. Ideally, access to the same electronic medical record system for communication between the primary care provider, specialists, nursing staff, and social workers would allow sharing of family communications, expected appointments, and ongoing medical issues. If this electronic medical record system is not available to all providers, communications should be outlined in writing to the comanagement collaborative.

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