P2.042: Developing and Sustaining a Pediatric Complex Care Program in Montana

Background: Montana is the fourth-largest state in the U.S. by land area but has the fewest pediatricians nationwide—approximately 115— most of whom practice in or near larger cities. Of Montana’s 1.137 million residents, 20.8% are under the age of 18, with an estimated 4.5% (~10,700 children) meeting criteria for medical complexity (CMC). Significant barriers to comprehensive care include limited pediatric-specific services, long travel distances (often 3-8+ hours) for subspecialty care, lack of in-state quaternary care, fragmented EMRs, and an absence of CMC-specific care coordination and reimbursement models. Despite these challenges, Montana had no formalized CMC programs before 2018. This report describes our efforts to establish and sustain a pediatric complex care program tailored to the state’s unique needs.

Methods: A formalized program for CMC was established within an integrated health system serving Montana and Wyoming, supported by local and system-level leadership. Modeled after programs in other states and refined with Six Sigma Black Belt input, it was adapted to meet Montana’s unique needs. A multidisciplinary team was formed, led by the system’s first outpatient pediatric care manager and a medical director practicing both complex and general pediatrics. The program provides primary or consultative care through in-person or virtual visits, integrating palliative care tenets to promote quality of life—and, when applicable, quality of death. EMR enhancements, including chart alerts, patient-specific care plans, and embedded fax tools, improved patient safety and streamlined communication. An AAP CATCH grant in 2018 was instrumental in building partnerships and trust across the state. A 2023 Healthy People 2030 grant further expanded impact through collaboration with Montana’s AAP Chapter and the Department of Public Health and Human Services to enhance state-wide provision of care to CMC.

Results: Since launching in April 2018, the program has received 266 referrals from Montana, North Dakota, and Wyoming. Of these, 50 did not meet criteria, 118 have discharged, and 92 remain active—63 in the primary care branch and 29 seen consultatively. Among active patients, 11 are tracheostomy-dependent and 43 are tube fed. Families report high satisfaction with access via electronic messaging, direct phone support, and priority assistance with acute needs. Referring providers have expressed appreciation for the program’s comprehensive chart reviews and complex care planning, which help streamline care across numerous healthcare systems for this patient population.

Conclusion: Our care model demonstrates that programs for CMC can thrive outside of tertiary or quaternary children’s hospitals. Through intentional design, system collaboration, and community-focused strategies, high-quality, sustainable care is achievable in rural settings. As complex care evolves nationally, our experience offers a replicable framework for frontier regions, highlighting the impact of flexible delivery models, strategic advocacy, and strong partnerships in reducing barriers and advancing care equity for children with medical complexity.