Abstract

In the early months of the COVID-19 pandemic surge, the virus predominantly impacted adult patients and therefore adult facilities began to look to pediatric facilities to support the sudden increase in patient volume. Combined Internal Medicine and Pediatrics trained clinicians found themselves at a unique intersection to support both the clinical as well as maneuver the systemic challenges to effectively operationalize the safe and equitable care of adult patients in pediatric facilities. From this need, the POPCoRN (Pediatric Overflow Planning Contingency Response Network) was created. The mission and vision of POPCoRN was formulated using the Theory of Change (ToC) framework.

 

Combined Internal Medicine and Pediatric clinicians have unique training that allows them to 1) see health systems and structures through broader perspectives  2) are accustomed to dynamically adapting to new and complex environments. The POPCoRN Network was able to leverage these invaluable skill-sets to rapidly evaluate local health systems and develop efficient and equitable down-stream, community-driven responses based on a broader ToC framework.

 

Text Body

When coronavirus made its way to the United States, many combined internal medicine and pediatrics (Med-Peds) providers found themselves grappling with how their pediatric systems could expand capacity to care for the expected surge of adult patients requiring acute care. As children were less likely than adults to require hospitalization with acute COVID-19 infection, pediatric facilities were then considered a potential resource for expanding a community’s hospital capacity with Med-Peds providers already service as a bridge between pediatric and adult medicine. However, there was varying levels of guidance on how they could and should 1) consolidate and coordinate pediatric care, and 2) expand capacity to care for adult patients safely, to optimize their community’s supply of acute care beds and needed supplies and staffing.¹

 

Incredible uncertainty exists around if and how to care for adults in pediatric settings, which became more apparent during the pandemic. Without a clear evidence base or best practices to guide implementation of these adult care models, a collaborative platform that promoted equitable sharing of experience and learning was imperative for rapid cycle planning and implementation during the pandemic. Further, a foundation of knowledge already existed with the growing number of institutions with Med-Peds led groups caring for adult populations in pediatric facilities due to increasing prevalence of adolescents and young adults with rare, complex, and historically fatal conditions.² Med-Peds physicians are often within multiple divisions, the network innately had further reaching effects in divisions of pediatrics, internal medicine and transitional medicine across the country. As the Pediatric Overflow Planning Contingency Response Network (POPCoRN) co-founders and leaders, our experiences as Med-Peds providers in our own communities and institutions helped us recognize the importance of an adaptive pandemic response through a collaborative network.

 

POPCoRN recognized early on that the COVID-19 crisis would more greatly impact our most in-need communities, facilities, and larger hospital systems. The network needed to be responsive to those needs and proactive in identifying systemic gaps in care equity.

To identify these needs and potential gaps, POPCoRN used a Theory of Change (ToC) approach to shape the mission, vision, and goals.³Briefly, this methodology helps to iteratively identify the root problems within a system, promoting a deeper understanding of the “why and from where” a systemic challenge has evolved, while the objective tree flips this methodology to support building infrastructure to dismantle the root etiology.³

 

Using the TOC approach included first contextualizing the pandemic and issues related to caring for adults in pediatric facilities with a problem tree, and then identifying necessary change with an objective tree.⁴ Our growing collaborative network determined health system fragmentation and the resulting 1) lack of coordinated response between pediatric and adult facilities in order to share resources; and 2) lack of effort devoted to health equity and justice as a root problems. This ultimately highlighted further the role med-peds providers have in this space in helping health systems flex capacity to care for new populations, especially those that require coordination between pediatric and adult systems. This applies not only for the care of patients who have childhood onset conditions or disabilities, but also more broadly for the impact of racial and social injustice on the health of communities and patients across the lifespan.

 

Med-Peds Providers as Change Agents

Drawing upon our training across systems as Med-Peds providers, POPCoRN served as an easily accessible, shared space to consolidate information, ask questions, solicit feedback, and build a community in real time. The unique cohesion of the national Med-Peds community was a huge asset in this planning and rapid information dissemination.

 

The POPCoRN network exemplifies the role med-peds providers, researchers, and health system leaders can have in identifying and mitigating health system fragmentation in a way that promotes health equity. Med-Peds providers have shown to be engaged as majority generalists both in the hospital setting as well in the outpatient and community settings,² resulting in a unique wide-systems based perspective. This experience erecting the POPCoRN network suggests that Med-Peds trained clinicians have a unique perspective to enacting and championing systems level change. ToC methodology has proven to be a successful way to build upon that perspective and adapt with the needs of the community.

 

The POPCoRN network quickly took off with the Med-Peds community as its backbone. As increasing numbers of individuals expressed interest in getting involved, the network grew organically to address the various needs of participants. Working groups were developed which addressed specific hospital settings (free standing children’s hospitals, integrated children’s and adult systems, community hospitals) as well as the knowledge gaps. Medical student members, especially those who had already identified as wanting to purse med-peds training, eager to provide support during the pandemic, were instrumental in providing administrative and logistical support. The network continues to grow with collaboration among health professionals from institutions across the globe. This pandemic and this network brought to light the invaluable niche med-peds providers can have on identifying and bridging the silos within our healthcare systems, quickly, effectively and collaboratively.

 

Adapting to National Events

As protests around racial justice broke out across the country, POPCoRN immediately identified the network should play in furthering conversations and operationalizing equitable and anti-racist practices within local hospital systems. Given that many of the inequities between hospital systems and resource deficiencies were among the root causes of our fragmented systems, POPCoRN leadership felt that this updated mission and vision not only fell within the projected Theory of Change but allowed us to more completely address branches of the solution tree.

 

Our Vision Forward – Continued Call to Action
The tragedy of the 2020 Coronavirus pandemic shed light on the role of Med-Peds providers. The ability to dynamically respond beyond just diverse clinical expertise is a newly recognized asset and has further deepened the embodiment of the POPCoRN theory of change.

With this sense of continued responsibility and appreciation for the unique Med-Peds training in a time of crisis, POPCoRN identified four essential mechanisms of change that remain guiding forces as the network continues to adapt to the dynamic pandemic environment:

 

1. Empowering and creating active roles for differing levels of learners to contribute (diversity of voice)
2. Inclusivity within the network (activities promoting wellness and community within all meetings promoting relationship building)
3. Minimizing barriers to contribute - encouraging participants to continue on cycle of participation/learning (no fees or registration, easy access to zoom and ability for fluctuating time-commitments)
4. Being dynamic in response, to help meet needs of participants (recognizing that we are responding in an everchanging time, and the needs of the community need to be constantly re-evaluated).

 

As the Med-Peds community, as well as the POPCoRN network continue to respond to an unforeseen future, let this be a call for continued systems level strategizing. Let’s use this unique role and training to continue to identify root causes to solve larger cross-system equity challenges that have gone too long neglected.

 

 

References:

¹Association CH. Children’s Hospitals’ Statement on Essential COVID-19 Relief. Accessed October 16, 2020. https://www.childrenshospitals.org/Newsroom/Press-Releases/2020/Childrens-Hospitals-Statement-on-Essential-COVID19-Relie

² Donnelly MJ, Thornton SC, Radabaugh CL, et al. Characteristics of the Combined Internal Medicine-Pediatrics Workforce. The American Journal of Medicine. doi:10.2105/AJPH.2020.305821

 

³  Using a Problem and Objective Tree to Set Realistic Goals. Accessed 16 October 2020.

https://www.thegrassrootscollective.org/problem-objective-tree-development

 

^4. Glenn M. Landers, Karen J. Minyard, Daniel Lanford, and Hilary Heishman, 2020:

A Theory of Change for Aligning Health Care, Public Health, and Social Services in the Time of COVID-19. American Journal of Public Health 110, S178_S180, https://doi.org/10.2105/AJPH.2020.305821