A recent definitional framework has been proposed that emphasizes 4 broad domains to characterize children with medical complexity (CMC): needs, chronic conditions, functional limitations, and health care use ().1,2
Regardless of underlying diagnoses, all CMC share similar functional and resource use consequences, including intensive hospital- and/or community-based service need; reliance on technology, polypharmacy, and/or home care or congregate care to maintain a basic quality of life; risk of frequent and prolonged hospitalizations leading to high health resource utilization; and an elevated need for care coordination.3
Definitional framework for children with medical complexity. (Reproduced with permission from Pediatrics, Vol. 127, Pages 529–538, Copyright 2011 by the AAP.)
Historically, although the inpatient management of some groups of CMC was claimed by ambulatory subspecialists (such as pediatric pulmonologists directing the inpatient care of children with cystic fibrosis), the inpatient management of other groups of CMC has been left to a wide variety of subspecialists and/or general pediatricians. For instance, a child with neurologic impairment necessitating hospital admission could have their inpatient care directed by any number of services, such as neurology, rehabilitation, pulmonology, various surgical subspecialties, or by a general pediatrician.1
The emerging field of complex care is focused on the holistic medical care of these children. Provision of complex care requires both broad general pediatrics skills4
and specific expertise in care coordination and communication with patients, families, and other medical and nonmedical care providers.5
Recent trends in inpatient care have demonstrated an increasingly complex inpatient environment because of the growth in children with complex and/or chronic diagnoses admitted to hospital,6,7
the inexorable specialization within health care, resulting in new services and technologies,8
an increasing demand to provide efficient and cost-effective inpatient care, and challenges in ensuring the smooth transitions in care both within hospitals9
and between hospitals and the community.10
Not surprisingly, many pediatric hospitalists have started to develop an interest in care coordination for CMC.3
In addition, because more and more hospitalized children have chronic illnesses11
and are responsible for a substantial proportion of resource utilization, pediatric hospitalists are in an ideal position to embrace complex care.6,7,12–14
Because of these factors, complex care has emerged as a field with many pediatric hospitalists at the helm, in arenas ranging from clinical care of these patients, research into their care, and education of future providers.
The objective of this section of the review article is to outline the past, present, and possible future of CMC within several arenas in the field of pediatric hospital medicine, including practice management, clinical care, research, education, and quality improvement.