Variations in state-level definitions: children with special health care needs

Interactions between special education teachers and children with chronic complex conditions: A qualitative study

Background

The number of children with complex medical conditions has increased in recent decades. In this context, a complex chronic condition is characterized by multiple morbidities that require intensive or continuous health care according to the level of severity. Given their various health conditions, it is challenging to provide special education to these children, but there is still insufficient evidence regarding the practical experiences of educators. The aim of this study was to investigate special education teacher's perceptions, experiences, and challenges while developing interpersonal relationships and communicating with children who have complex chronic conditions.

Methods

We recruited and interviewed 21 special education school teachers in Japan. The transcripts of the interviews were analyzed using thematic analysis.

Results

Our analysis revealed four themes, including "searching for the meaning," "complex chronic conditions as a difficult reality," "widening experience for the future," and "priority for interacting with children." These themes reflect the perceptions, experiences, and challenges of the special education teachers.

Conclusions

In cases where children have severe functional limitations, it is more challenging to understand child-teacher interactions. This highlights the importance of searching for meaning in educational practices used among children with complex chronic conditions. Our findings may provide helpful insight into the experiences and challenges faced by special educators who engage with these children.

Identifying Children with Special Health Care Needs Using Medicaid Data in New York State Medicaid Managed Care

OBJECTIVE

The ability to identify children with special health care needs (CSHCN) is crucial to evaluate disparities in the quality of health care for children in Medicaid Managed Care. We developed and assessed the accuracy of a new method to classify CSHCN.

DATA SOURCES

Secondary data analysis was conducted using NYS Medicaid administrative data and the Children with Chronic Conditions Screener (CCC Screener).

STUDY DESIGN

This study included 5,907 NYS Medicaid beneficiaries (17 years old or younger) whose parents completed the CCC Screener in 2014. Medicaid administrative data were used to create a risk score to assess the risk of special needs, and a cut point was identified to differentiate between children with versus without special needs. Diagnostic accuracy of the method was assessed using sensitivity and specificity analyses.

PRINCIPAL FINDINGS

Applying the CCC Screener as the "gold standard," the risk score correctly classified the majority of CSHCN as positive (sensitivity = 75 percent) and the majority of the children without special needs as negative (specificity = 79 percent). This method demonstrated decent diagnostic ability (AUC = 0.77).

CONCLUSIONS

Our method can identify CSHCN in the NYS Medicaid Managed Care population and will help the State monitor the quality of care for this vulnerable population.

Do unmet needs differ geographically for children with special health care needs?

The purpose of this study was to identify geographic differences in health indicators for children with special health care needs (CSHCN). It was hypothesized that geographic differences in unmet health care needs exist among CSHCN by region in the United States. Data were obtained from the National Survey of Children with Special Health Care Needs, 2005-2006. Nine variables representing unmet needs were analyzed by geographic region. The region with the highest percent of unmet needs was identified for each service. Logistic regression was utilized to determine differences by region after controlling for age, gender, ethnicity, race, federal poverty level, relationship of responder to child, insurance status, severity of condition, and size of household. A total of 40,723 CSHCN were represented. Crude analysis demonstrated that the greatest unmet need for routine preventive care, specialist care, prescription medications, physical/occupational/speech therapy, mental health care, and genetic counseling occurred in the West. The greatest unmet need for preventive dental care, respite care, and vision care occurred in the South. Significant differences between regions remained for six of the nine services after controlling for potential confounders. Geographic differences in unmet health care needs exist for CSHCN. Further delving into these differences provides valuable information for program and policy planning and development. Meeting the needs of CSHCN is important to reduce cost burden and improve quality of life for the affected child and care providers.

Risk of losing insurance during the transition into adulthood among insured youth with disabilities

To compare insured youth (age 15-25 years) with and without disabilities on risk of insurance loss. We conducted a cross-sectional study using data from the Survey of Income and Program Participation 2001. Descriptive statistics characterized insured youth who maintained and lost insurance for at least 3 months over a 3-year time frame. We conducted logistic regression to calculate the association between disability and insurance loss. Adjustment variables were gender, race, ethnicity, age, work or school status, poverty status, type of insurance at study onset, state generosity, and an interaction between disability and insurance type. This study includes 2,123 insured youth without disabilities, 320 insured youth with non-severe disabilities, and 295 insured youth with severe disabilities. Thirty-six percent of insured youth without disabilities lost insurance compared to 43% of insured youth with non-severe disabilities and 41% of insured youth with severe disabilities (P = .07). Youth with non-severe disabilities on public insurance have an estimated 61% lower odds of losing insurance (OR: 0.39; 95% CI: 0.16, 0.93; P = .03) compared to youth without disabilities on public insurance. Further, youth with severe disabilities on public insurance have an estimated 81% lower odds of losing insurance (OR: 0.19; 95% CI: 0.09, 0.40; P < .001) compared to youth without disabilities. When examining youth with private insurance, we find that youth with severe disabilities have 1.63 times higher odds (OR: 1.63; 95% CI: 1.03, 2.57; P = .04) of losing health insurance compared to youth without disabilities. Insurance type interacts with disability severity to affect odds of insurance loss among insured youth.

Methods for developing useful estimates of the costs associated with birth defects

BACKGROUND

Cost estimates for birth defects are useful to policy makers in deciding the best use of resources to prevent these conditions. Much of the effort in this area has focused on spina bifida, in part because cost savings can be estimated from folic acid-preventable cases. However, comprehensive cost-of-illness estimates for this condition may be too outdated, too general, or not applicable to individual states' environments.

METHODS

Using the live birth prevalence for spina bifida in Texas, we applied recent spina bifida cost estimates to approximate total lifetime medical and other costs for an average live birth cohort of spina bifida cases in Texas. In addition, we queried various government programs that provide services for persons with spina bifida to provide program-specific annual costs for this condition.

RESULTS

Applying a recently published average lifetime medical cost of $635,000 per case of spina bifida to the average annual birth cohort of 120 Texas cases, an estimated $76 million in direct and indirect medical and other costs will be incurred in Texas over the life span of that cohort. Examples of estimated medical costs for one year are $5 million for infants using actual employer-paid insurance claims data and $6 million combined for children in two public sector programs.

DISCUSSION

Stakeholders and state policy makers may look to state birth defects registries for useful cost data. Although comprehensive state-specific figures are not available, applying prevalence data to existing estimates and obtaining actual claims and program expenditures may help close this information gap.

Defining chronic diseases and health conditions in childhood (0-18 years of age): national consensus in the Netherlands

A national consensus procedure was organised to define chronic diseases and health conditions in childhood. Based on (1) a systematic literature search on the definitions of chronic conditions in childhood and (2) a theoretical framework of determinants and indicators of health conditions, a definition of chronic conditions in childhood was proposed. This proposal was subsequently modified according to the comments received from 21 Dutch experts (clinicians, researchers and representatives of patient organisations) in two written consultation rounds and one national meeting, until consensus was reached. Consensus was attained on a definition consisting of four criteria: a disease or condition is considered to be a chronic condition in childhood if: (1) it occurs in children aged 0 up to 18 years; (2) the diagnosis is based on medical scientific knowledge and can be established using reproducible and valid methods or instruments according to professional standards; (3) it is not (yet) curable or, for mental health conditions, if it is highly resistant to treatment and (4) it has been present for longer than three months or it will, very probably, last longer than three months, or it has occurred three times or more during the past year and will probably reoccur. This definition was operationalised using the ICD-10 classification of the World Health Organisation (WHO; International Statistical Classification of Diseases and Related Health Problems [ICD], 10th revision, Geneva, Switzerland, 1992). By this systematic and thorough procedure, national consensus on a comprehensive definition of chronic conditions in children which can be used for epidemiological research was reached.

Access to care for youth with special health care needs in the transition to adulthood

PURPOSE

To describe access to care and identify factors associated with access for low-income young adults who aged out of a public program for children with special health care needs (CSHCN).

METHODS

This was a cross-sectional survey of graduates of the Title V CSHCN program in one California county. Subjects were 77 graduates (55% female) aged 21-24 years with ongoing health care needs. Measures of access to care included having the following: a regular source of care for the main health condition; all needed care since turning 21 years of age; any delayed or forgone care in the past 6 months; health insurance; and continual insurance since turning age 21. Individuals lacking any one access measure were defined as experiencing an adverse transition event.

RESULTS

Of the subjects, 24% lacked a usual source of health care, 27% had gone without some needed health care since turning 21, and 39% had delayed needed care. Although 10% of respondents were uninsured at the time of the survey; 40% had a gap in insurance coverage since turning age 21. Overall, 65% reported at least one adverse transition event affecting access to care. Factors associated with experiencing no adverse transition event were receiving Supplemental Security Income (SSI, p = .007), having received special education services (p = .003), and having been born with the main health condition (p = .013).

CONCLUSIONS

Insurance gaps and delayed care are prevalent among these low-income young adults despite ongoing health problems. Greater transition support might improve access by linking them with a usual source of care, identifying insurance options, and encouraging regular use of care.

Conceptualizing childhood health problems using survey data: a comparison of key indicators

Background

Many definitions are being used to conceptualize child health problems. With survey data, commonly used indicators for identifying children with health problems have included chronic condition checklists, measures of activity limitations, elevated service use, and health utility thresholds. This study compares these different indicators in terms of the prevalence rates elicited, and in terms of how the subgroups identified differ.

Methods

Secondary data analyses used data from the National Longitudinal Survey of Children and Youth, which surveyed a nationally representative sample of Canadian children (n = 13,790). Descriptive analyses compared healthy children to those with health problems, as classified by any of the key indicators. Additional analyses examined differences between subgroups of children captured by a single indicator and those described as having health problems by multiple indicators.

Results

This study demonstrates that children captured by any of the indicators had poorer health than healthy children, despite the fact that over half the sample (52.2%) was characterized as having a health problem by at least one indicator. Rates of child ill health differed by indicator; 5.6% had an activity limitation, 9.2% exhibited a severe health difficulty, 31.7% reported a chronic condition, and 36.6% had elevated service use. Further, the four key indicators captured different types of children. Indicator groupings differed on child and socio-demographic factors. Compared to children identified by more than one indicator, those identified only by the severe health difficulty indicator displayed more cognitive problems (p < 0.0001), those identified only by the chronic condition checklist had a greater likelihood of reporting allergies or asthma (p < 0.0001), and those identified as having elevated service use only were more affluent (p = 0.01) and showed better overall health (p < 0.0001). Children identified by only a single indicator were less likely to have serious health problems than those identified by two or more indicators.

Conclusion

We provide information useful to researchers when selecting indicators from survey data to identify children with health problems. Researchers and policy makers need to be aware of the impact of such definitions on prevalence rates as well as on the composition of children classified as being in poor health.

Unmet need and problems accessing specialty medical and related services among children with special health care needs

OBJECTIVES

To extend what is known about parent reports of their child's need for specialty medical and related services, unmet need, and specific types of access problems among children with special health care needs (CSHCN).

METHODS

Using data from a 1998-1999 20-state survey of families of CSHCN, we examined differences in parent report of need for services by child characteristics, investigated parent report of unmet need and access problems by service area and number of services needed, and estimated the likelihood of four access problems and unmet need by child, family, and health insurance characteristics.

RESULTS

Overall, the sample children had numerous service needs, although the prevalence of need varied by service type and child characteristics. Reports of unmet need were greater for older children and for children with multiple service needs, unstable health care needs or a behavioral health condition, parents who were in poor health or had more than a high school education, and families whose insurance coverage was inconsistent or lacked a secondary plan. Reports of access problems were greatest for mental health and home health services. The two most prevalent access problems were finding a skilled provider and getting enough visits.

CONCLUSIONS

The results underscore the importance of finding new ways to link children with behavioral health problems to mental health services, implementing coordinated care and the other core dimensions of the medical home concept, increasing the number of specialty pediatricians and home health providers, and expanding coverage for a wider range of mental health services.

Family reports of care denials for children enrolled in TennCare

OBJECTIVE

Twenty-three million people, accounting for >58% of Medicaid enrollees, are enrolled in Medicaid managed care programs. Although the expectation of management in Medicaid managed care programs necessitates restrictions in use of some services sought by patients and families, the circumstances surrounding care denial and related access problems in vulnerable populations of children have not been studied. The objective of this study was to identify experiences with care denial reported by families in TennCare, Tennessee's managed care program for Medicaid enrollees and uninsured.

METHODS

Primary caregivers for 399 children who were enrolled in TennCare and presented for care at 21 pediatric and family medicine sites throughout Tennessee participated in a face-to-face interview.

RESULTS

Of the 399 caregivers who participated in the study, 146 (36.6%) reported that their child experienced denial of care in the previous 12 months at a physician's office (12.5% of those interviewed), dentist's office (13.8%), or pharmacy (20.0%). For denial of any 1 type of care, families of children with chronic conditions (multivariable odds ratio [OR]: 2.05; 95% confidence interval [CI]: 1.41-2.99) and those whose parents had >12 years of education (OR: 1.80; CI: 1.21-2.70) were more likely to report denial of care; families of black children were less likely to report denial than white children (OR: 0.34; CI: 0.20-0.56). Content analysis of caregiver perceptions identified provider concerns about reimbursement as a factor in denials. Of the children who could not be seen by a physician, caregivers perceived that 12.2% became sicker as a result of the delay in care; 16.3% reported an emergency department visit after the denial.

CONCLUSIONS

More than one third of TennCare families reported denials of care for their children in the previous year, and factors surrounding these denials were identified. Given the large number of Americans who receive health care through Medicaid managed care programs like TennCare, more research is needed to understand the implications of denied care for children and families who are enrolled in these programs.