The Aerodigestive Team Present and Future Paul Boesch

The Aerodigestive Team: Present and Future Paul Boesch Joel Friedlaner Gresham Richter Scott Schraff David White

The Origin of Aerodigestive Care

Pediatric Aerodigestive Center Oto-HNS GI Speech Pulmonary

Pediatric Aerodigestive Center Pediatric Surgery Dietician Oto-HNS Sleep Medicine Genetics GI Speech Pulmonary Allergy/Imm unology Cardiothoracic Surgery

Search: [state name] + aerodigestive + children’s Pediatric Aerodigestive Centers

What is the current state of cohesiveness of Aerodigestive Teams? Should there be an over-arching strategy for Aerodigestive Care among the teams?

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?

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?

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

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

Small to midsized Children’s Hospitals • “Let’s develop an aerodigestive program” • Limited experience in… 1. Coordinating services 2. Establishing finances/business plan 3. Leadership (operational-business) • The process in developing such centers in smaller institutions is not clear

Objective To provide a framework and dialogue to initiate a pediatric aerodigestive center in smaller institutions

• 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

Challenges • Grasping the concept • Political landscape • Management differences among disciplines – Training and perspectives – Personalities? • Coordination of schedules • Institutional finances • Institutional support • Patient selection

Buzz Meetings The beginning. Discussions Clinic

Generating “The Buzz” • Perioperative/clinic discussions – Excitement and interest – Identifying key players • Multiple emails to colleagues and chiefs – – Otolaryngology Gastroenterology Pulmonary Speech Therapy • Presenting it as a leadership opportunity

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

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) 1. Allows the team to hash out differences and meet on common ground in managing patients 2. Establishes truly interested players 3. Need at least two members per discipline

• • Otolaryngology Gastroenterology Pulmonology Speech Therapy Nutrition General Surgery Psychology Team

Timeline Buzz 6 months-1 year Meetings Discussions 6 months-1 year Clinic 6 months-1 year

The Clinic • Multidisciplinary – 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

• Start small The Clinic – 1/4 -1/2 day – 6 patients • Use ENT clinic – Establish the pace early – Does not retract from medical services volume • One Coordinator

Buzz Meetings Clinic Colleagues Patients Cli nic N th u o ote Aerodigestive Center s Clinic VP Senior Administration ord W M f o

The Buzz: Populating the clinic Colleagues Patients Administration Referrals

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

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

Benefits • Coordinate Care in single visit • 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/Manus cripts • Regional recognition • Patient capture from other institutions

Outcome variables • Decreased variability • Efficient use of resources • Surveys • Safety – Care coordination, education and communication – One anesthesia exposure

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

Service ENT Clinical Care Provided Level 4 encounter GI Level 4 encounter PULM Level 4 encounter Speech Nutrition CXR VFSS CT chest Brain MRI Charge Service Care Provided ENT DL GI EGD Surgery Pulmonary Flex Bronch Charge

Risks/Costs To Implement • Currently no additional • Future Employment • Specialty nurse 0. 5 FTE: 50 K/yr • Admin Assistant 0. 5 FTE: 30 K/yr Risk of not implementing • 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

The first step?

• Good Mentors – Well developed careers – No competing interests – Have something to gain from your success – Internal and External • Unchartered Territory – Institutional – Clinical – Research

Start keeping tabs { DATA COLLECTION

Success Blind Luck True Grit

Academic Luck Knowing opportunity when you see it

FIRST 2 -3 YEARS

• • Volunteer for committees Assist with other department needs Find opportunities to teach Get others excited and involved

But be true to your limitations

The Promise 9% 10% 23% 58% Clinical Research Administrative Education Academic Percentages

The Reality 7% 3%4% Clinical Research Administrative Education 86% Academic Percentages

Set the wheels in motion

Delegate and Trust

Your sphere of influence

THANKYOU! GTRichter@uams. edu

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?

What are some delivery-of-care innovations that will keep our kids out of the OR? Other adoptions of technology?

Innovation in Aerodigestive Medicine Joel Friedlander Associate Professor of Pediatrics Digestive Health Institute Aerodigestive Program

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

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

Innovation GI • Improving efficiencies and clinic flow with medical, surgical, non medical specialties/Targeted Evaluations • Pharmaceutical and Device Trials • Aerodigestive Training/Fellowships • Crosstraining • 3 d Imaging and Modeling • Advanced coordinated interventional procedures

Thank You Christopher. t. wootten@vanderbilt. edu