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The Aerodigestive Team: Present and Future
Paul Boesch Joel Friedlaner Gresham Richter Scott Schraff David White
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The Origin of Aerodigestive Care
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Pediatric Aerodigestive Center
Oto-HNS Speech Pulmonary GI
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Pediatric Aerodigestive Center
Pediatric Surgery Dietician Oto-HNS Speech Pulmonary GI Allergy/Immunology Sleep Medicine Cardiothoracic Surgery Genetics
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Pediatric Aerodigestive Centers
Search: [state name] + aerodigestive + children’s Pediatric Aerodigestive Centers
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What is the current state of cohesiveness of Aerodigestive Teams
What is the current state of cohesiveness of Aerodigestive Teams? Should there be an over-arching strategy for Aerodigestive Care among the teams?
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Can we supply a definition of Aerodigestive Care
Can we supply a definition of Aerodigestive Care? What is the understanding of Aerodigestive Care in the world around us? What might an educational agenda look like among the Aerodigestive Teams? Research agenda?
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Give an overview of the Delphi Study on Aerodigestive care
Give an overview of the Delphi Study on Aerodigestive care. How can individuals find leadership and career advancement through multidisciplinary work? Does the team threaten the individual?
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Establishing Pediatric Aerodigestive Centers
Leadership and Academic Advancement in a mid-sized children’s hospital Gresham T Richter, MD FACS Professor and Chief of Pediatric Otolaryngology University of Arkansas School of Medicine Arkansas Children’s Hospital
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Pediatric Aerodigestive Centers
Coordinating the care of complex patients with upper airway issues complicated by gastrointestinal and lower airway conditions Well established centers in large institutions
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Small to midsized Children’s Hospitals
“Let’s develop an aerodigestive program” Limited experience in… Coordinating services Establishing finances/business plan Leadership (operational-business) The process in developing such centers in smaller institutions is not clear
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Objective To provide a framework and dialogue to initiate a pediatric aerodigestive center in smaller institutions
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How do we define Aerodigestive Disease?
Patients who require a cadre of disciplines to manage conditions that, when compounded, affect entire upper aerodigestive health Types of patients Chronic Vent and Trach? Upper airway obstruction ? Pharyngeal dysphagia
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Challenges Coordination of schedules Grasping the concept
Institutional finances Institutional support Patient selection Grasping the concept Political landscape Management differences among disciplines Training and perspectives Personalities?
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Buzz Meetings Discussions Clinic The beginning.
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Generating “The Buzz” Perioperative/clinic discussions
Excitement and interest Identifying key players Multiple s to colleagues and chiefs Otolaryngology Gastroenterology Pulmonary Speech Therapy Presenting it as a leadership opportunity
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The Buzz: Utilizing otolaryngology
50% patients with aerodigestive issues Dedicated speech pathologist Highest biller in their program Must be knowledgeable Gets early speech involvement Establish a fledgling “aerodigestive” clinic with otolaryngology and speech Helps generate productivity platform
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The Meetings Thought alignment
Monthly multidisciplinary meetings to discuss common but complicated patients 1 hour only Power-point presentations 15 minutes Rotated among disciplines Controversial topics (GERD, LPR, Nissan, VFSS) Allows the team to hash out differences and meet on common ground in managing patients Establishes truly interested players Need at least two members per discipline
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Team Otolaryngology Gastroenterology Pulmonology Speech Therapy
Nutrition General Surgery Psychology Team
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Timeline Meetings Buzz Clinic Discussions 6months-1 year
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The Clinic Multidisciplinary Immediately after clinic
Many first patients generated from team Core participants GI, Pulm, Speech, ENT, Nutrition, Resp Rx Immediately after clinic All patients discussed Guarantees all team members will be present
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The Clinic Start small Use ENT clinic One Coordinator 1/4-1/2 day
6 patients Use ENT clinic Establish the pace early Does not retract from medical services volume One Coordinator
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Senior Administration
Aerodigestive Center Clinic Meetings Buzz Colleagues Patients Word of Mouth Clinic Notes Clinic VP Senior Administration
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The Buzz: Populating the clinic
Referrals Patients Colleagues Administration
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Keeping the Energy Integrate responsibility
Two members from each discipline Director: Co-Directors ---Gastroenterology --Pulmonology --Speech Initiate research to academic advancement Involve everyone in each project
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Selling Administration
You have now demonstrated that its feasible Now the hard-work Multiple meetings VP Finance Demonstrate benefit Establish a business plan Public Relations
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Benefits Coordinate Care in single visit Improved patient satisfaction
Each visit=5 encounters Next day interventions Mayo Model approach to medicine Better communication Among Services With patients Improved patient satisfaction Academic productivity Data collection Presentation/Manuscripts Regional recognition Patient capture from other institutions
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Outcome variables Decreased variability Efficient use of resources
Surveys Safety Care coordination, education and communication One anesthesia exposure
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Improved Revenue Capture
Clinic Operative 5 billable encounters for each visit CXR each patient/each visit PFT ¼ patients Increased billing level per encounter CT-Chest 1/10 patients Low DKNA Rate Upgraded modifier per medical consultant MRI brain ¼ VFSS same day=1/4 Bronchoscopy EGD Microlaryngoscopy
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Clinical Surgery Service Care Provided Charge ENT Level 4 encounter GI
PULM Speech Nutrition CXR VFSS CT chest Brain MRI Service Care Provided Charge ENT DL GI EGD Pulmonary Flex Bronch Clinical Surgery
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Risks/Costs To Implement Risk of not implementing
Currently no additional Future Employment Specialty nurse 0.5 FTE: 50K/yr Admin Assistant 0.5 FTE: 30K/yr Loss of market share being sent to other children’s hospitals with aerodigestive Center Poor communication Impacts care Impacts continuity Impacts patient satisfaction National Reputation
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The first step?
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Unchartered Territory
Institutional Clinical Research Good Mentors Well developed careers No competing interests Have something to gain from your success Internal and External
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Start keeping tabs DATA COLLECTION
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Success Blind Luck True Grit
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Knowing opportunity when you see it
Academic Luck Knowing opportunity when you see it
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FIRST 2-3 YEARS
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Volunteer for committees
Assist with other department needs Find opportunities to teach Get others excited and involved
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But be true to your limitations
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Academic Percentages
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Academic Percentages
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Set the wheels in motion
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Delegate and Trust
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Your sphere of influence
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THANKYOU!
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What are some pearls and pitfalls of Aerodigestive care in a private or semi-private model? What is your experience providing airway care in the developing world?
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What are some delivery-of-care innovations that will keep our kids out of the OR? Other adoptions of technology?
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Innovation in Aerodigestive Medicine
Joel Friedlander Associate Professor of Pediatrics Digestive Health Institute Aerodigestive Program
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Disclosure/COI This talk will discuss off-label use of medical and surgical devices that are authorized by the FDA I currently hold a patent on a currently-not available endoscope device. No other conflicts of interest
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Innovation GI Unsedated in office procedures for evaluation of GERD and follow up of findings during the triple scope Wireless technologies Innovation of the Medical Home and where does it belong? PEG’s in Aero as compared to General GI Utilization of General Physicians vs Advance Practice Providers (NP/PA) to optimize efficiency and maintain quality Coordination of electronic intake and database/Quality Improvement
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Innovation GI Improving efficiencies and clinic flow with medical, surgical, non medical specialties/Targeted Evaluations Pharmaceutical and Device Trials Aerodigestive Training/Fellowships Crosstraining 3d Imaging and Modeling Advanced coordinated interventional procedures
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Thank You
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