Utilization and costs for children who have special health care needs and are enrolled in a hospital-based comprehensive primary care clinic

Medical home quality and readmission risk for children hospitalized with asthma exacerbations

OBJECTIVE

The medical home likely has a positive effect on outpatient outcomes for children with asthma. However, no information is available regarding the impact of medical home quality on health care utilization after hospitalizations. We sought to explore the relationship between medical home quality and readmission risk in children hospitalized for asthma exacerbations.

METHODS

We enrolled 601 children, aged 1 to 16 years, hospitalized for an acute asthma exacerbation at a single pediatric facility that captures >85% of all asthma admissions in an 8-county area. Caregivers completed the Parent's Perception of Primary Care (P3C), a Likert-based, validated survey. The P3C yields a total score of medical home quality and 6 subscale scores assessing continuity, access, contextual knowledge, comprehensiveness, communication, and coordination. Asthma readmission events were prospectively collected via billing data. Hazards of readmission were calculated by using Cox proportional hazards adjusting for chronic asthma severity and key measures of socioeconomic status.

RESULTS

Overall P3C score was not associated with readmission. Among the subscale comparisons, only children with lowest access had a statistically increased readmission risk compared with children with the best access. Subgroup analysis revealed that children with private insurance and good access had the lowest rates of readmission within a year compared with other combinations of insurance and access.

CONCLUSIONS

Among measured aspects of medical home in a cohort of hospitalized children with asthma, having poor access to a medical home was the only measure associated with increased readmission. Improving physician access for children with asthma may lower hospital readmission.

Pediatric hospital medicine and children with medical complexity: past, present, and future

Children with medical complexity, regardless of underlying diagnoses, share similar functional and resource use consequences, including: intensive service needs, reliance on technology, polypharmacy, and/or home care or congregate care to maintain a basic quality of life, high health resource utilization, and, an elevated need for care coordination. The emerging field of complex care is focused on the holistic medical care of these children, which requires both broad general pediatrics skills and specific expertise in care coordination and communication with patients, families, and other medical and non-medical care providers. Many pediatric hospitalists have developed an interest in care coordination for CMC, and pediatric hospitalists are in an ideal location to embrace complex care. As a result 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 children with medical complexity within several arenas in the field of pediatric hospital medicine, including practice management, clinical care, research, education, and quality improvement.

Health care use and expenditures associated with access to the medical home for children and youth

BACKGROUND

The pediatric medical home is an approach to the delivery of family-centered health care. Policy-makers and payers are interested in potential changes to health care utilization and expenditures under this model.

OBJECTIVE

To test associations between having a medical home and health service use and expenditures among US children and youth.

RESEARCH DESIGN

Observational cross-sectional study.

SUBJECTS

A total of 26,221 children aged 0 to 17 years surveyed in the 2005 to 2007 Medical Expenditure Panel Surveys.

MEASURES

Parent report of a child's access to a medical home was developed from multiple survey items in the Medical Expenditure Panel Surveys. Negative binomial regression examined the association between the medical home and parent-reported counts of annual outpatient, inpatient, emergency department, and dental visits. Two-part models examined associations between the medical home and parent-reported annual total, outpatient, inpatient, emergency department, and other health care expenditures. Models accounted for potential self-selection into a medical home using propensity scores.

RESULTS

Children with a medical home had a greater incidence of preventive visits [incidence rate ratio (IRR)=1.11; (95% confidence intervals (CI), 1.03-1.20)] and dental visits [IRR=1.09 (95% CI, 1.02-1.17)] and a lower incidence of emergency department visits [IRR=0.87 (95% CI, 0.79-0.97)] compared with children without a medical home. Children with a medical home also had greater odds of incurring total, outpatient, prescription medication, and dental expenditures, OR's ranging from 1.09 to 1.38. Despite greater odds of incurring certain expenditures, expenditures were no different for children with and without a medical home.

CONCLUSIONS

The medical home is associated with several domains of health service use, yet there is no evidence for its association with health care expenditures for children and youth.

Current state of high-risk infant follow-up care in the United States: results of a national survey of academic follow-up programs

OBJECTIVE

High-risk infant follow-up programs have the potential to act as multipurpose clinics by providing continuity of clinical care, education of health care trainees and facilitating outcome data research. Currently there are no nationally representative data on high-risk infant follow-up practices in the United States. The objective of this study is to collect information about the composition of high-risk infant follow-up programs associated with academic centers in the United States, with respect to their structure, function, funding resources and developmental assessment practices, and to identify the barriers to establishment of such programs.

STUDY DESIGN

Staff neonatologists, follow-up program directors and division directors of 170 Neonatal Intensive Care Units (NICU) associated with pediatric residency programs were invited to participate in an anonymous online survey from October 2009 to January 2010.

RESULT

The overall response rate was 84%. Ninety three percent of the respondents have a follow-up program associated with their NICU. Birth weight, gestational age and critical illness in the NICU were the major criteria for follow-up care. Management of nutrition and neurodevelopmental assessments was the most common service provided. Over 70% have health care trainees in the clinic. About 75% of the respondents have the neurodevelopmental outcome data available. Most of the respondents reported multiple funding sources. Lack of personnel and funding were the most common causes for not having a follow-up program.

CONCLUSION

High-risk infant follow-up programs associated with academic centers in the United States are functioning as multidisciplinary programs providing clinical care, trainee education and facilitating outcomes research.

Medical transport of children with complex chronic conditions

One of the most notable trends in child health has been the increase in the number of children with special health care needs, including those with complex chronic conditions. Care of these children accounts for a growing fraction of health care resources. We examine recent developments in health care, especially with regard to medical transport and prehospital care, that have emerged to adapt to this remarkable demographic trend. One such development is the focus on care coordination, including the dissemination of the patient-centered medical home concept. In the prehospital setting, the need for greater coordination has catalyzed the development of the emergency information form. Training programs for prehospital providers now incorporate specific modules for children with complex conditions. Another notable trend is the shift to a family-centered model of care. We explore efforts toward regionalization of care, including the development of specialized pediatric transport teams, and conclude with recommendations for a research agenda.

Care coordination for children with complex care needs significantly reduces hospital utilization

PURPOSE

The purpose was to evaluate an ambulatory care coordination program for children with complex care needs.

DESIGN AND METHODS

A pre- and postcohort evaluation design was implemented to analyze the impact on hospital utilization.

RESULTS

Results included a decrease in emergency department presentations (15%, p < .001), hospital admissions (9%, p < .019), and hospital bed days (43%, p < .001). Economic analysis indicated a cost savings of $A 1.9 million per annum.

PRACTICE IMPLICATIONS

Hospital utilization is significantly reduced for children with complex care needs through 24/7 care coordination.

Hospital-based comprehensive care programs for children with special health care needs: a systematic review

OBJECTIVE

To examine the effectiveness of hospital-based comprehensive care programs in improving the quality of care for children with special health care needs.

DATA SOURCES

A systematic review was conducted using Ovid MEDLINE, CINAHL, EMBASE, PsycINFO, Sociological Abstracts SocioFile, and Web of Science.

STUDY SELECTION

Evaluations of comprehensive care programs for categorical (those with single disease) and noncategorical groups of children with special health care needs were included. Selected articles were reviewed independently by 2 raters.

DATA EXTRACTION

Models of care focused on comprehensive care based at least partially in a hospital setting. The main outcome measures were the proportions of studies demonstrating improvement in the Institute of Medicine's quality-of-care domains (effectiveness of care, efficiency of care, patient or family centeredness, patient safety, timeliness of care, and equity of care).

DATA SYNTHESIS

Thirty-three unique programs were included, 13 (39%) of which were randomized controlled trials. Improved outcomes most commonly reported were efficiency of care (64% [49 of 76 outcomes]), effectiveness of care (60% [57 of 95 outcomes]), and patient or family centeredness (53% [10 of 19 outcomes). Outcomes less commonly evaluated were patient safety (9% [3 of 33 programs]), timeliness of care (6% [2 of 33 programs]), and equity of care (0%). Randomized controlled trials occurred more frequently in studies evaluating categorical vs noncategorical disease populations (11 of 17 [65%] vs 2 of 16 [17%], P = .008).

CONCLUSIONS

Although positive, the evidence supporting comprehensive hospital-based programs for children with special health care needs is restricted primarily to nonexperimental studies of children with categorical diseases and is limited by inadequate outcome measures. Additional high-quality evidence with appropriate comparative groups and broad outcomes is necessary to justify continued development and growth of programs for broad groups of children with special health care needs.

Characteristics of hospitalizations for patients who use a structured clinical care program for children with medical complexity

OBJECTIVE

To describe the characteristics of hospitalizations for patients who use clinical programs that provide care coordination for children with multiple, chronic medical conditions.

STUDY DESIGN

Retrospective analysis of 1083 patients hospitalized between June 2006 and July 2008 who used a structured, pediatric complex-care clinical program within 4 children's hospitals. Chronic diagnosis prevalence (ie, technology assistance, neurologic impairment, and other complex chronic conditions), inpatient resource utilization (ie, length of stay, 30-day readmission), and reasons for hospitalization were assessed across the programs.

RESULTS

Over the 2-year study period, complex-care program patients experienced a mean of 3.1 ± 2.8 admissions, a mean length of hospital stay per admission of 12.2 ± 25.5 days, and a 30-day hospital readmission rate of 25.4%. Neurologic impairment (57%) and presence of a gastrostomy tube (56%) were the most common clinical characteristics of program patients. Notable reasons for admission included major surgery (47.1%), medical technology malfunction (9.0%), seizure (6.4%), aspiration pneumonia (3.9%), vomiting/feeding difficulties (3.4%), and asthma (1.8%).

CONCLUSIONS

Hospitalized patients who used a structured clinical program for children with medical complexity experienced lengthy hospitalizations with high early readmission rates. Reducing hospital readmission may be one potential strategy for decreasing inpatient expenditures in this group of children with high resource utilization.

Pediatric hospitalists' perspectives on the care of children with medical complexity

OBJECTIVE

The aims of this study were to identify pediatric hospitalists' perceived views of (1) barriers to delivering care to children with medical complexity (CMC) and (2) their preferred model of inpatient health care delivery for CMC.

SUBJECTS

American Academy of Pediatrics Section on Hospital Medicine (AAP-SOHM) Listserv subscribers.

METHODS

We conducted a cross-sectional survey of subscribers of the AAP-SOHM Listserv using the survey instrument SurveyMonkey®. Our survey was coadministered with a survey on pediatric hospitalist career satisfaction.

RESULTS

The most significant barriers to delivering care to CMC were (1) time constraints (89%), (2) inadequate postdischarge resources (75%), and (3) lack of evidence-based guidelines (64%). Although most pediatric hospitalists in an inpatient service currently care for both CMC and non-CMC patients (91%), only 25% perceive this to be the optimal service model for CMC. The majority of hospitalists (56%) believe that CMC are better served by either an inpatient service dedicated to CMC (30%) or comanaged with an inpatient consult service for CMC (26%).

CONCLUSIONS

Identifying the perceived barriers to delivering care to CMC can assist pediatric hospitalists to design studies determining if care delivery is affected by these barriers. Most hospitalists care for CMC on the same service as uncomplicated patients, yet over half perceive that a different model of care delivery would better serve the needs of CMC.

Children with medical complexity: an emerging population for clinical and research initiatives

Children with medical complexity (CMC) have medical fragility and intensive care needs that are not easily met by existing health care models. CMC may have a congenital or acquired multisystem disease, a severe neurologic condition with marked functional impairment, and/or technology dependence for activities of daily living. Although these children are at risk of poor health and family outcomes, there are few well-characterized clinical initiatives and research efforts devoted to improving their care. In this article, we present a definitional framework of CMC that consists of substantial family-identified service needs, characteristic chronic and severe conditions, functional limitations, and high health care use. We explore the diversity of existing care models and apply the principles of the chronic care model to address the clinical needs of CMC. Finally, we suggest a research agenda that uses a uniform definition to accurately describe the population and to evaluate outcomes from the perspectives of the child, the family, and the broader health care system.

Pediatric resident attitudes toward caring for children with severe disabilities

OBJECTIVE

To survey pediatric residents' attitudes toward caring for children with severe disabilities.

DESIGN

A cross-sectional survey of residents in a university-affiliated pediatric residency program between October and December 2005. Residents were asked to complete a newly designed, 13-item survey. For each item, participants selected the degree to which they did or did not agree with a statement about disabilities or caring for children with severe disabilities.

RESULTS

Fifty-five (43%) of 129 eligible residents participated. Eighty-nine percent felt that caring for children with severe disabilities was as rewarding as caring for other children. Ninety-two percent felt that there is a societal responsibility to care for such children; 98% felt families of children with disabilities love their children as much as other families. Two-thirds (66%) admitted frustration related to caring for children who cannot be cured or function independently, and 71% questioned the aggressive treatment of such children. Residents in their second and third postgraduate years were more likely to question the aggressive treatment compared with their junior colleagues.

CONCLUSIONS

Although pediatric residents had positive attitudes toward children with severe disabilities, emotional and moral tensions did arise around their care.

The impact of a complex care clinic in a children's hospital

BACKGROUND

The number of medically complex and fragile children (MCFC) cared for in children's hospitals is growing, necessitating the need for optimal care co-ordination. The purpose of this study was to describe the impact of a nurse practitioner/paediatrician-run complex care clinic in a tertiary care hospital on healthcare utilization, parental and primary care provider (PCP) perceptions of care and parental quality of life.

METHODS

MCFC and their parents were recruited for ambulatory follow-up by the hospital team to complement care provided by the PCP in this mixed methods single centre pre- or post-evaluative study. Parents participated in semi-structured interviews within 48 h of discharge; further data were collected at 6 and 12 months. Healthcare utilization was compared with equal time periods pre-enrolment. Parental health was assessed with the SF-36; parental perceptions of care were assessed using the Larsen's Client Satisfaction Questionnaire and the Measure of Processes of Care; PCPs completed a questionnaire at 12 months. Parental and PCP comments were elicited. Comparisons were made with baseline data.

RESULTS

Twenty-six children and their parental caregivers attended the complex care clinic. The number of days that children were admitted to hospital decreased from a median of 43 to 15 days, and outpatient visits increased from 2 to 8. Mean standardized scores on the SF-36 increased (improved) for three domains related to mental health. A total of 24 PCPs responded to the questionnaire (92% response); most found the clinic helpful for MCFC and their families. Parents reported improvements in continuity of care, family-centredness of care, comprehensiveness and thoroughness of care, but still experienced frustrations with access to services and miscommunication with the team.

CONCLUSION

A collaborative medical home focused on integrating community- and hospital-based services for MCFC is a promising service delivery model for future controlled evaluative studies.

Benefits of care coordination for children with complex disease: a pilot medical home project in a resident teaching clinic

OBJECTIVE

To study the integration of comprehensive care coordination for children with complex disease in our resident education clinic at University of California Los Angeles by analyzing alterations in medical resource use.

STUDY DESIGN

The Pediatric Medical Home Project at University of California Los Angeles was designed to include 4 basic elements: 1) 60-minute intake appointment; 2) follow-up appointments twice the length of a standard visit; 3) access to a "family liaison"; and 4) a family notebook ("All about Me" binder). From the initial cohort of 43 patients, encounter data on 30 were analyzed to determine use of outpatient, urgent, emergency department (ED), and inpatient services. Encounters for each patient were compared for a period of 1 year before and 1 year after enrollment.

RESULTS

The average number of ED visits per patient decreased from 1.1 +/- 1.7 before enrollment to 0.5 +/- 0.9 after medical home enrollment (P = .02). However, no significant change was found in use of any of the other health care resources studied.

CONCLUSIONS

Incorporating a program of care coordination according to the principles of the medical home into an outpatient pediatric residency teaching clinic may not only serve as a training vehicle for pediatric residents, but also create favorable alterations in medical resource use.

A review of the evidence for the medical home for children with special health care needs

CONTEXT

The receipt of health care in a medical home is increasingly touted as a fundamental basis for improved care for persons with chronic conditions, yet the evidence for this claim has not been systematically assessed.

OBJECTIVE

Our goal was to determine the evidence for the federal Maternal and Child Health Bureau recommendation that children with special health care needs receive ongoing comprehensive care within a medical home.

METHODS

We searched the nursing and medical literature, references of selected articles, and requested expert recommendations. Search terms included children with special health care needs, medical home-related interventions, and health-related outcomes. Articles that met defined criteria (eg, children with special health care needs, United States-based, quantitative) were selected. We extracted data, including design, population characteristics, sample size, intervention, and findings from each article.

RESULTS

We selected 33 articles that reported on 30 distinct studies, 10 of which were comparison-group studies. None of the studies examined the medical home in its entirety. Although tempered by weak designs, inconsistent definitions and extent of medical home attributes, and inconsistent outcome measures, the preponderance of evidence supported a positive relationship between the medical home and desired outcomes, such as better health status, timeliness of care, family centeredness, and improved family functioning.

CONCLUSIONS

The evidence provides moderate support for the hypothesis that medical homes provide improved health-related outcomes for children with special health care needs. Additional studies with comparison groups encompassing all or most of the attributes of the medical home need to be undertaken.

A home for medically complex children: the role of hospital programs

The medical home is a conceptual model of continuous and comprehensive care provision that is associated with improved outcomes for children with special healthcare needs. Most applications of the medical home have focused on improving primary care services. Despite concerted efforts to apply the medical home concept to the care of children with special healthcare needs, many barriers to its implementation still exist, in particular, for the subset of children with special healthcare needs who are medically complex. Applying the medical home concept to hospital-based care coordination may benefit both children with complex conditions and their families, as well as the community-based providers.

A medical home center: specializing in the care of children with special health care needs of high intensity

OBJECTIVE

Children with special health care needs (CSHCN) benefit from a medical home, however, a subset, those children with high intensity needs, have medical and social service issues beyond the capacity of most primary care practices. We describe a novel medical home center that is designed to meet the needs of children with special health care needs of high intensity (CSHCN-HI).

MODEL OF CARE

The medical home center, U Special Kids (USK) is located at the University of Minnesota and affiliated with a tertiary medical center. USK serves CSHCN-HI throughout the state of Minnesota and, because of state supported funding for the program, children have access to the program regardless of their health insurance coverage. The team is expert at gathering an overall perspective of the child's needs, identifying gaps, accessing services and weaving together the plethora of disparate services, agencies and providers. A major goal of this model is to transition care from USK to a primary care medical home within the child's community. Transition is more likely to occur optimally once the child's complex needs are organized, the family is trained, adequate management resources are in place, and the intensity of care coordination needs are reduced.

CONCLUSIONS

We propose that, in addition to a primary care medical home, CSHCN-HI benefit from a unique medical home center that can provide sufficient resources and expertise to organize their complex care coordination needs. Medical home centers, designed specifically to manage the care of children with complex high intensity medical and care coordination needs, have the potential to reduce excess health care utilization and improve patient outcomes by providing this group of children with customized, accessible and integrated services.