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When it comes to pediatric surgical care, Lucile Packard Children’s Hospital has turned the traditional model on its head. Through a network of outreach clinics spanning the western United States, Packard now brings its world-class surgeons to the patients, rather than the other way around.
“We’ve really focused on a new approach, where our surgical team reaches out to hospitals that don’t have the expertise we do to perform pediatric procedures in their communities,” says Frank Hanley, MD, executive director of the Children’s Heart Center at Packard Children’s and the Lawrence Crowley Professor in Child Health.
As pediatric surgery becomes more complex and specialized, many regional hospitals face the daunting task of providing highly specialized care for children with rare diagnoses, an issue compounded by limited staff and declining budgets.
In response, Packard Children’s has established a network that now encompasses strategic partnerships as far afield as Tacoma, Albuquerque, Honolulu, and Billings, Mont. Outreach clinics provide services in many pediatric surgical specialties, including organ transplantation, cardiovascular surgery, orthopedics, and urology. Packard experts offer a full range of surgical skills, from diagnosis to follow-up care and ongoing rehabilitation.
“Children and their families benefit, as do the hospitals in the network, which can perform more effectively,” says Craig Albanese, MD, the John A. and Cynthia Fry Gunn Endowed Director of Pediatric Surgical Services. “The partnerships we’ve established offer a full spectrum of care that serves the needs of different communities. Instead of a hospital referring children to us, we send our experts to them.”
Packard Children’s has developed several different models—tailored to specific facilities and needs—that help bring surgeons to outlying communities. These models range from “borrowing” space for monthly clinics to embedding a Packard surgical team on site that is fully integrated with the host hospital’s staff.
The working model at Good Samaritan Hospital in San Jose, for example, was established five years ago in collaboration with Packard’s pediatric surgery service. With no children’s hospital in the South Bay, Packard opened an outpatient clinic in Los Gatos. In a short time the small, stand-alone facility began offering urology, pulmonary, gastroenterology, and general surgery clinics several days a week. Today, a pediatric general surgery team works alongside Good Samaritan pediatric anesthesiologists, nurses, and staff to provide full-time, inpatient care.
“We saw a real need to reach out to this area because so many of our patients live down here,” says Gary Hartman, MD, director of regional pediatric surgery services at Packard Children’s and chief of pediatric general surgery at Good Samaritan. “We did a careful survey of the community physicians, and they identified the biggest demands.”
Hartman and his team treat anything from hernias to appendicitis in Good Samaritan’s Children’s Surgery Center, which features specialized laparoscopic instruments and an adjacent pediatric intensive care unit. Complex surgeries that require more advanced equipment are transferred to Packard’s main hospital.
“Our relationship here represents a strong commitment to the needs of children,” Hartman explains. “It’s a partnership with the pediatricians and the families in the community. But the best benefit is that people don’t have to travel as far to receive the same high standards of care.”
That concern for the patient experience is echoed by William Kennedy, MD, associate chief of pediatric urology, who oversees outpatient surgical services at four partner institutions, including John Muir Hospital in Walnut Creek, Dominican Hospital in Santa Cruz, the Pediatric Group of Monterey, and California Pacific Medical Center in San Francisco. “I don’t mind the travel if it helps make my patients more relaxed and happy. People want to be able to have their care delivered closer to home. Isn’t it better if one person drives so that eight families don’t have to?”
Kennedy remembers one incident in particular: The family lived in the East Bay and had been coming to Packard for follow-up care after a surgical procedure. Kennedy saw the patient about a year later after he was established at John Muir. “I remember the mother looking at me, and saying, ‘Can I level with you? I finally understand what is going on with my child.’ After packing her kids in the car and driving for an hour and a half, she arrived at Packard completely frazzled and tired, so she couldn’t focus properly on the content of the visit. Now she drives to their appointment in five minutes and arrives alert and refreshed. That, in a nutshell, is why outreach is so important.”
The flexibility of the Packard outreach model enables surgeons in different specialties to tailor their services to patient needs. For example, because most pediatric urology surgeries do not involve life-threatening conditions, the large majority of children Kennedy sees receive outpatient procedures, and about half are one-time services. Patients who require long-term or follow-up care are best off closer to home, where they can be followed by their family pediatrician, Kennedy explains.
“We’ve created our partnerships very carefully so the highest quality of care is maintained,” he says. “We work closely with our colleagues to learn what they need. We maintain an open dialogue at all times. We’re there to help them and work alongside them to provide the best care for the child.”
At Santa Clara Valley Medical Center in San Jose, Julie Fuchs, MD, oversees seven surgeons who provide consultation, inpatient and outpatient surgery, and outpatient clinical care and follow-up. The team provides the same specialized services patients receive at Packard, including treatment of the full range of neonatal congenital problems.
Orthopedic surgeon Lawrence Rinsky, MD, established a pediatric clinic at Santa Clara Valley in 2010. Today, he and his team see between 80 and 100 patients each week for consult, scheduling, and follow-up care. Twice a month they operate on approximately 10 patients, taking care of fractures, hip and foot disorders, and musculoskeletal diseases. Complex spine surgeries are transferred to Packard, which has the specialized technology for such delicate procedures.
Children in isolated areas of Lake Tahoe, the eastern Sierra, and northern Nevada—where regional medical institutions lack resources for specialized pediatric neurosurgery—are seen in Packard outreach clinics for diagnostic and ongoing care. Coordinated by neurosurgeon Michael Edwards, MD, the Lucile Packard Children’s Hospital Endowed Professor in Pediatric Neurosurgery and Pediatrics, the clinics are organized according to the needs of the community and the facilities available at each site. At St. Rose Dominican Hospital in Henderson, Nev., for example, a former Stanford pediatric neurosurgery fellow sees patients daily, making referrals to Packard Children’s that cannot be accommodated on site.
Another model, established in Reno, maintains a biweekly diagnostic clinic in association with Sierra Neurosurgery Group, where a Packard caregiver determines the best site for surgery. In the past six months, only a few select patients were transferred to Packard Children’s because of the complexity of the surgery.
“The key is to establish good relationships and good communication. Often these hospitals have limited resources for complex pediatric neurosurgery,” Edwards says. “They have asked us to step in to help, and we want to work with them. It’s a nice opportunity to develop future relationships for referrals and training.”
Participating surgeons say they enjoy the challenge of reaching out to new communities of families and developing new clinical programs, while still receiving the support and connection of Packard Children’s.
“I have the opportunity to build something new, and I like the responsibility of treating interesting cases,” says Claudia Mueller, PhD, MD, surgical lead at California Pacific Medical Center (CPMC) in San Francisco. Mueller works full-time at CPMC in a partnership that was launched just last October. In a few shorts months she has handled more than 100 inpatient and outpatient surgeries, and she serves as the point person for follow-up care.
“It’s a happy marriage: We integrate the best of what Packard has to offer with the best of what CPMC already has in place,” says Mueller, the Tashia and John Morgridge Endowed Faculty Scholar in Pediatric Translational Medicine. “Our patients don’t get just one surgeon—they benefit from the whole Packard team approach. It really is the best of both worlds for all involved.”
The benefits of this outreach program go both ways. Packard surgeons are able to practice their craft and hone their skills for caring for children with both routine needs and with rare or unusual conditions.
“We provide outstanding surgical services to families that otherwise might not have access to that level of expertise,” says Hanley, “and we dramatically expand the patient base to allow for robust clinical research that advances the standard of care.”
“Packard has great specialty expertise. But you need complex cases to maintain proficiency,” adds Claire Mailhot, RN, EdD, director of planning for children’s surgical services. “Expertise and experience improve not just the surgery, but the care before and after.
“For example,” she says, “our cardiac teams need a minimum of 250 cases to keep up proficiencies in cardiology, radiology, and related specialties. Pediatric neurosurgery is another area that’s so subspecialized that the procedures are best performed in centers where they are done frequently.”
The network also creates expanded opportunities for education. “For residents, there’s a larger population to serve and a better chance for follow-through,” says Rinsky. “If a patient needs to come to Packard, there’s also better continuity of care.”
“Thanks to our outreach network,” adds Hartman, “patients can get world-class surgical care closer to home. It’s like having Packard in your own backyard.”