Unmet Need for Care Coordination Among Children with Special Health Care Needs

Supporting the Well-Being of Children and Youth With Special Health Care Needs: NASEM Proceedings

Children and youth with special health care needs (CYSHCN) are living longer than ever. These advances come with a price: Patients, families, communities, and systems must absorb the challenges of chronic caregiving, including protracted stress and poor mental health. In 2023, the National Academies of Science, Engineering, and Medicine convened thought-leaders for conversations about supporting the emotional well-being of CYSHCN and their families. Invited panelists included 2 parents and 3 academic pediatricians. Parents suggested opportunities for clinicians and systems to better support CYSHCN. Clinicians described work focused on: Individual patient- and family-level resilience: Defined as a process of harnessing resources to sustain well-being in the face of stress, resilience is learnable. Programs that teach people to identify and bolster "resilience resources" show promise in improving child and caregiver mental health;Clinician- and practice-level provision of care: Individual-level interventions are only effective if clinicians know when and how to deliver them. Hence, the American Board of Pediatrics created and demonstrated the success of a "roadmap" to support routine screening for and discussion of social and emotional health needs; andSystems-level barriers: Even with patient-level programs and clinician-practice guidance, unmet social and mental health needs persist. Accessing and coordinating services is difficult, may not be covered by insurance, and historically marginalized populations are the least likely to benefit. Together, the panel underscored a critical fact: We cannot optimize child and family well-being without focusing on patients, caregivers, clinicians, and systems.

Integrated care for children and young people with special health and care needs: a systematic review

CONTEXT

There is a dearth of high-quality evidence on integrated, coordinated and cost-effective care for children with special health and care needs (CSHCN).

OBJECTIVE

To assess the effectiveness of integrated/coordinated care models for CSHCN.

DATA SOURCES

Embase, Ovid Medline(R), HMIC Health Management Information Consortium, Maternity & Infant Care Database (MIDIRS), PsycARTICLES, PsycINFO, Social Policy and Practice, Cochrane Central Register of Controlled Trials (CENTRAL), Global Health and PubMed.

STUDY SELECTION

Inclusion criteria comprised (1) randomised trials, including cluster randomised trials; (2) an integrated/coordinated care intervention; (3) for children and young people under 25 with special healthcare needs including medical complexity; (4) assessing child-centred outcomes, health-related quality of life among parents and carers, and health or social care use, processes of care and satisfaction with care.

DATA EXTRACTION

Data were extracted and assessed by two researchers, and descriptive data were synthesised according to outcome and intervention.

RESULTS

14 randomised controlled studies were included. Seven out of the 14 studies had a dedicated key worker/care coordinator as a vital part of the integrated/coordinated care intervention; however, the certainty of evidence for all outcomes was either 'low' or 'very low'.

LIMITATIONS

Included studies were mostly from high-income countries. Variable study outcomes and quality of evidence precluded meta-analysis.

CONCLUSIONS

Limited evidence favours integrated care for CSHCN using a dedicated key worker/care coordinator; however, heterogeneity in study outcomes and definitions of CSHCN limit the strength and utility of evidence obtained. Recommendations are made for improving integrated care practice, research and evaluation which are important for evidence-based health services for CSHCN.

PROSPERO REGISTRATION NUMBER

CRD42020209320.

Urban Rural Differences on Accessing Patient- Centered Medical Home Among Children With Mental/Developmental Health Conditions/Disorders

INTRODUCTION

To address healthcare spending growth and coordinated primary care, most states in the United States have adopted patient-centered medical homes (PCMHs). To evaluate urban rural difference on accessing PCMH among US children, particularly for children with developmental disabilities (DDs) and mental health disorders (MHDs).

METHODS

This cross-sectional study used the 2016-2018 National Survey for Children's Health (NSCH). Multivariable adjusted logistic regression analyses were used to assess the association between accessing PCMHs and rurality and mental/developmental conditions/disorders.

RESULTS

Children with both DDs and MHDs were statistically significantly higher in rural areas (10.9% rural vs. 8.3% urban, p ≤ .001). Children in rural areas reported higher odds of accessing PCMHs (14%) among all U.S. children, but no differences by subgroups for children with MHDs and/or DDs. Compared with children without DDs/MHDs, the reduction in access to PCMHs varies by children's health status (41% reduction for children both DDs and MHDs, 25% reduction for children with MHDs without DDs) effects. Children with MHDs/DDs were less likely to receive family-centered care, care coordination, and referrals.

CONCLUSIONS

Quality improvements through PCMHs could focus on family-centered care, care coordination, and referrals. Patient-centered medical home performance measurement could be improved to better measure mental health integration and geographical differences.

Medication Management Through Collaborative Practice for Children With Medical Complexity: A Prospective Case Series

OBJECTIVE

Care coordination for children and youth with special health care needs and medical complexity (CYSHCN-CMC), especially medication management, is difficult for providers, parents/caregivers, and -patients. This report describes the creation of a clinical pharmacotherapy practice in a pediatric long-term care facility (pLTCF), application of standard operating procedures to guide comprehensive medication management (CMM), and establishment of a collaborative practice agreement (CPA) to guide drug therapy.

METHODS

In a prospective case series, 102 patients characterized as CYSHCN-CMC were included in this pLTCF quality improvement project during a 9-month period.

RESULTS

Pharmacists identified, prevented, or resolved 1355 drug therapy problems (DTP) with an average of 13 interventions per patient. The patients averaged 9.5 complex chronic medical conditions with a -median length of stay of 2815 days (7.7 years). The most common medications discontinued due to pharmacist assessment and recommendation included diphenhydramine, albuterol, sodium phosphate enema, ipratropium, and metoclopramide. The average number of medications per patient was reduced from 23 to 20. A pharmacoeconomic analysis of 244 of the interventions revealed a monthly direct cost savings of $44,304 ($434 per patient per month) and monthly cost avoidance of $48,835 ($479 per patient per month). Twenty-eight ED visits/admissions and 61 clinic and urgent care visits were avoided. Hospital -readmissions were reduced by 44%. Pharmacist recommendations had a 98% acceptance rate.

CONCLUSIONS

Use of a CPA to conduct CMM in CYSHCN-CMC decreased medication burden, resolved, and prevented adverse events, reduced health care-related costs, reduced hospital readmissions and was well-accepted and implemented collaboratively with pLTCF providers.

Family-centred care interventions for children with chronic conditions: A scoping review

INTRODUCTION

Children with chronic conditions have greater health care needs than the general paediatric population but may not receive care that centres their needs and preferences as identified by their families. Clinicians and researchers are interested in developing interventions to improve family-centred care need information about the characteristics of existing interventions, their development and the domains of family-centred care that they address. We conducted a scoping review that aimed to identify and characterize recent family-centred interventions designed to improve experiences with care for children with chronic conditions.

METHODS

We searched Medline, Embase, PsycInfo and Cochrane databases, and grey literature sources for relevant articles or documents published between 1 January 2019 and 11 August 2020 (databases) or 7-20 October 2020 (grey literature). Primary studies with ≥10 participants, clinical practice guidelines and theoretical articles describing family-centred interventions that aimed to improve experiences with care for children with chronic conditions were eligible. Following citation and full-text screening by two reviewers working independently, we charted data covering study characteristics and interventions from eligible reports and synthesized interventions by domains of family-centred care.

RESULTS

Our search identified 2882 citations, from which 63 articles describing 61 unique interventions met the eligibility criteria and were included in this review. The most common study designs were quasiexperimental studies (n = 18), randomized controlled trials (n = 11) and qualitative and mixed-methods studies (n = 9 each). The most frequently addressed domains of family-centred care were communication and information provision (n = 45), family involvement in care (n = 37) and access to care (n = 30).

CONCLUSION

This review, which identified 61 unique interventions aimed at improving family-centred care for children with chronic conditions across a range of settings, is a concrete resource for researchers, health care providers and administrators interested in improving care for this high-needs population.

PATIENT OR PUBLIC CONTRIBUTION

This study was co-developed with three patient partner co-investigators, all of whom are individuals with lived experiences of rare chronic diseases as parents and/or patients and have prior experience in patient engagement in research (I. J., N. P., M. S.). These patient partner co-investigators contributed to this study at all stages, from conceptualization to dissemination.

Adverse Social Determinants of Health and Gaps in Care Coordination Among Children

Gaps in care coordination (CC) can have detrimental impacts on children's health. It is unclear how much adverse social determinants of health (SDoH) may affect CC gaps. We determined whether exposure to adverse SDoH is associated with experiencing more gaps in CC using a representative national sample of children. Children with inadequate or no health insurance (adjusted odds ratio [aOR] = 2.41; 95% confidence interval [CI], 2.19-2.66) and living in disadvantaged neighborhoods (aOR = 1.53; 95% CI, 1.33-1.75) have a higher likelihood of having gaps in CC, as do those with higher counts of adverse SDoH (aOR = 2.17; 95% CI, 1.85-2.53). Thus, interventions to improve CC for children should consider adverse SDoH.

Socioeconomic status and healthcare utilization disparities among children with epilepsy in the United States: Results from a nationally representative sample

Epilepsy affects 1% of the US population. Healthcare disparities are well-studied among adults with epilepsy but less so among children. We examined whether children with epilepsy (1) have lower income than or (2) utilize the emergency department (ED) differently from children without epilepsy, and (3) if income moderates ED utilization. Data from the 2016-2019 National Survey of Children's Health were used to identify children with active "epilepsy or seizure disorder". Children with versus without epilepsy were compared. Income and ED visits were modeled with logistic and Poisson regressions. This analysis included 131,326 children; 835 were diagnosed with epilepsy. Estimated population prevalence of epilepsy was 0.6%. Children from higher-income-households were less likely to have epilepsy (aOR: 0.7). Children with epilepsy were more likely to visit EDs (aOR = 10.2), see healthcare professionals (aOR: 2.7), and receive care from specialists (aOR: 10.3). Income moderated the relationship between having epilepsy and ED visits. 7.7% of children with epilepsy did not receive needed healthcare. Some barriers were acquiring appointments (aOR: 3.9) and transportation (aOR: 4.7). In conclusion, children with epilepsy were more likely than children without epilepsy to live in lower-income-households, visit EDs, see healthcare professionals, and not receive needed healthcare. Barrier-specific policy interventions may improve medical access for children with epilepsy.

Cost, Utilization, and Patient and Family Experience With ACO-Based Pediatric Care Management

BACKGROUND AND OBJECTIVES

Children and Youth with Special Health Care Needs have high healthcare utilization, fragmented care, and unmet health needs. Accountable Care Organizations (ACOs) increasingly use pediatric care management to improve quality and reduce unnecessary utilization. We evaluated effects of pediatric care management on total medical expense (TME) and utilization; perceived quality of care coordination, unmet needs, and patient and family experience; and differential impact by payor, risk score, care manager discipline, and behavioral health diagnosis.

METHODS

Mixed-methods analysis including claims using quasi-stepped-wedge design pre and postenrollment to estimate difference-in-differences, participant survey, and semistructured interviews. Participants included 1321 patients with medical, behavioral, or social needs, high utilization, in Medicaid or commercial ACOs, and enrolled in multidisciplinary, primary care-embedded care management.

RESULTS

TME significantly declined 1 to 6 months postenrollment and continued through 19 to 24 months (-$645.48 per member per month, P < .001). Emergency department and inpatient utilization significantly decreased 7 to 12 months post-enrollment and persisted through 19 to 24 months (-29% emergency department, P = .012; -82% inpatient, P < .001). Of respondents, 87.2% of survey respondents were somewhat or very satisfied with care coordination, 56.1% received education coordination when needed, and 81.5% had no unmet health needs. Emergency department or inpatient utilization decreases were consistent across payors and care manager disciplines, occurred sooner with behavioral health diagnoses, and were significant among children with above-median risk scores. Satisfaction and experience were equivalent across groups, with more unmet needs and frustration with above-median risk scores.

CONCLUSIONS

Pediatric care management in multipayor ACOs may effectively reduce TME and utilization and clinically provide high-quality care coordination, including education and family stress, with high participant satisfaction.

Inequities in Time Spent Coordinating Care for Children and Youth With Special Health Care Needs

OBJECTIVE

In the United States, caregivers of children and youth with special health care needs (CYSHCN) must navigate complex, inefficient health care and insurance systems to access medical care. We assessed for sociodemographic inequities in time spent coordinating care for CYSHCN and examined the association between time spent coordinating care and forgone medical care.

METHODS

This cross-sectional study used data from the 2018-2020 National Survey of Children's Health, which included 102,740 children across all 50 states. We described the time spent coordinating care for children with less complex special health care needs (SHCN) (managed through medications) and more complex SHCN (resulting in functional limitations or requiring specialized therapies). We examined race-, ethnicity-, income-, and insurance-based differences in time spent coordinating care among CYSHCN and used multivariable logistic regression to examine the association between time spent coordinating care and forgone medical care.

RESULTS

Over 40% of caregivers of children with more complex SHCN reported spending time coordinating their children's care each week. CYSHCN whose caregivers spent ≥ 5 h/wk on care coordination were disproportionately Hispanic, low-income, and publicly insured or uninsured. Increased time spent coordinating care was associated with an increasing probability of forgone medical care: 6.7% for children whose caregivers spent no weekly time coordinating care versus 9.4% for< 1 hour; 11.4% for 1 to 4 hours; and 15.8% for ≥ 5 hours.

CONCLUSIONS

Reducing time spent coordinating care and providing additional support to low-income and minoritized caregivers may be beneficial for pediatric payers, policymakers, and health systems aiming to promote equitable access to health care for CYSHCN.

Readiness for transition to adult health care among US adolescents, 2016-2020

OBJECTIVE

Adolescence is a critical period of transition from paediatric to adult health care, but readiness for this transition has been described as low in the general adolescent population. We aimed to investigate whether transition readiness improved over time among US adolescents and to examine associations between demographic and clinical characteristics and transition readiness over time.

METHODS

Deidentified caregiver-reported repeated cross-sectional data from the 2016-2020 National Survey of Children's Health were analysed for caregiver-reported measures of transition readiness among adolescents age 12-17 years. Logistic regression was used to identify trends in transition readiness and change over time in factors associated with this outcome.

RESULTS

Among 55 022 adolescents represented in the five survey years, the proportion meeting a composite definition of transition readiness increased from 15% (95% confidence interval [CI]: 14%, 16%) in 2016 to 19% (95% CI: 17%, 20%) in 2020. After multivariable adjustment, each additional year was associated with 12% greater odds of caregiver-reported transition readiness (95% CI: +8%, +15%; P < 0.001), and transition readiness was more likely for girls, older adolescents and adolescents with special health care needs. Associations between adolescent characteristics and transition readiness did not change over the study period.

CONCLUSIONS

Population-level caregiver-reported transition readiness among US adolescents has increased but remains low. Factors previously associated with transition readiness (age, sex, race and ethnicity, family income and presence of special health care needs) have persisted over recent years.

Care coordination and unmet need for specialised health services among children with special healthcare needs in the USA: results from a cross-sectional analysis of the national survey of children with special healthcare needs

OBJECTIVE

To report rates of need and unmet need for specialised health services (occupational and speech therapies, durable medical equipment, home healthcare, and mobility and communication aids) from the National Survey of Children with Special Health Care Needs (CSHCN) (2009/2010) and assess the role of care coordination in having needs met. We distinguish between CSHCN with and without emotional, behavioural and developmental disorders (EBDPs) in the USA.

DESIGN

A cross sectional cohort study of a nationally representative sample of CSHCN from the National Survey of CSHCN for 2009/2010 used logistic regression to assess the relationship between EBDPs and need and unmet need for specialised services. It also estimates the association of care coordination with unmet need for all services, for CSHCN with and without EBDPs.

SETTING

A nationally representative sample of CSHCN in the USA.

PARTICIPANTS

Children ages 0-17 years of age.

RESULTS

Across all specialised health services, rates of unmet need were at or below 25%. Need and unmet need for most services was higher among CSHCN with EBDPs than those without. For CSHCN with and without EBDPs, adequate care coordination was associated with greater probability of having needs for therapy, home health and communication aids met.

CONCLUSION

Care coordination is essential to reducing barriers to a wide range of healthcare services for CSCHN. Policies requiring adequate insurance coverage for care coordination may play a critical role in ensuring access to specialised health services.

Clusters of adverse childhood experiences and unmet need for care coordination

BACKGROUND

The lack of consensus on how to measure ACEs limits our estimation of their impact on health outcomes and understanding of which ACE clusters drive unmet care coordination (CC) needs.

OBJECTIVES

1) Identify latent classes of ACEs among a representative group of U.S. children; 2) Examine the association between these classes and unmet needs for CC.

PARTICIPANT AND SETTING

Using the 2016-2017 National Survey of Children's Health, we sampled children ages 0-17 the who had seen >1 healthcare provider within 12 months (n = 38,758).

METHODS

We conducted latent class analyses and weighted logistic regression analyses to examine associations between latent classes and unmet need for CC.

RESULTS

We identified seven distinct classes: household poverty and parental divorce, household poverty and parental death, household poverty only, household substance abuse and witnessing violence, multiple ACEs, household poverty and child discrimination, and household poverty and household mental illness. Children in the following classes had the greatest odds of unmet need for CC: household poverty only (AOR 2.0; 95% CI, 1.42-2.84), household poverty and household mental illness (AOR 1.67; 95% CI, 1.15-2.44), multiple ACEs (AOR 2.31; 95% CI, 1.53-3.50), and household poverty and child discrimination (AOR 3.55; 95% CI, 1.71-7.37).

CONCLUSIONS

Children who experienced specific combinations of ACEs, have an increased risk of unmet need for CC, with those experiencing both poverty and discrimination having the highest odds of unmet need for CC. Discrimination widens the gap of unmet CC need for poor children.

Outpatient Follow-up Care After Hospital Discharge of Children With Complex Chronic Conditions at a Rural Tertiary Care Hospital

OBJECTIVE

To determine factors associated with completion of recommended outpatient follow-up visits in children with complex chronic conditions (CCCs) following hospital discharge.

METHODS

We retrospectively identified children aged 1 to 17 years diagnosed with a CCC who were discharged from our rural tertiary care children's hospital between 2017 and 2018 with a diagnosis meeting published CCC criteria. Patients discharged from the neonatal intensive care unit and patients enrolled in a care coordination program for technology-dependent children were excluded.

RESULTS

Of 113 eligible patients, 77 (68%) had outpatient follow-up consistent with discharge instructions. Intensive care unit (ICU) admission (P = .020) and prolonged length of stay (P = .004) were associated with decreased likelihood of completing recommended follow-up.

CONCLUSIONS

Among children with CCCs who were not already enrolled in a care coordination program, ICU admission was associated with increased risk of not completing recommended outpatient follow-up. This population could be targeted for expanded care coordination efforts.

Associations between Adverse Childhood Experiences and Need and Unmet Need for Care Coordination

INTRODUCTION

Children exposed to adverse childhood experiences (ACEs) may access multiple systems of care to address medical and social complexities. Care coordination (CC) optimizes health outcomes for children with special health care needs who often use multiple systems of care. Little is known about whether ACEs are associated with need and unmet need for CC.

METHODS

Use of the 2016-2017 National Survey of Children's Health to identify children who saw ≥1 health care provider in the last 12 months. The study team used weighted logistic regression analyses to examine associations between 9 ACE types, ACE score and need and unmet need for CC.

RESULTS

In the sample (N=39,219, representing 38,316,004 US children), material hardship (aOR, 1.50; 95% CI, 1.29-1.75), parental mental illness (aOR, 1.31; 95% CI, 1.07-1.60), and neighborhood violence (aOR, 1.33; 95% CI, 1.01-1.74) were significantly associated with an increased need for CC. Material hardship was also associated with unmet need for CC (aOR, 2.37; 95% CI, 1.80 - 3.11). Children with ACE scores of 1, 2, 3, and ≥4 had higher odds of need and unmet need for CC than children with 0 ACEs.

DISCUSSION

Specific ACE types and higher ACE scores were associated with need and unmet need for CC. Evaluating the unique needs of children who endured ACEs should be considered in the design and implementation of CC processes in the pediatric healthcare system.

Predictors of Unmet Family Support Service Needs in Families of Children with Special Health Care Needs

OBJECTIVES

This study describes rates of perceived and unmet need for family support services (care coordination, respite care, and family mental health care) among a national sample of children with special health care needs (CSHCN), distinguishing children with emotional, behavioral, or developmental problems (EBDPs) from children with primarily physical chronic conditions. It also examines if a child having EBDPs is associated with perceived and unmet family support service needs and investigates public versus private health insurance's moderating effect on this association.

METHODS

Using data from the National Survey of Children with Special Health Care Needs (2005/2006 and 2009/2010), this cross-sectional study uses multi-level, fixed effects logistic regression.

RESULTS

When compared to CSHCN with no EBDPs, parents of CSHCN with EBDPs report greater need for all family support services and greater rates of unmet need for all support services. This pattern of greater need for CSHCN with EBDPs versus those without is similar among those with public and private health insurance. Among CSHCN with family support needs, however, the pattern differs. For CSHCN with EBDPs, having public insurance is associated with lower probabilities of unmet needs compared to private insurance. For CSHCN without EBDPs, having public insurance has a mixed effect on probability of reporting unmet need.

CONCLUSION

Having EBDPs and public insurance is associated with increased perceived need, but public insurance also confers particular benefit for children with EBDPs.

Public Health Coverage and Access to Mental Health Care for Youth with Complex Behavioral Healthcare Needs

Drawing upon the National Survey of Children with Special Healthcare Needs (2009/2010), multilevel logistic regression analysis assessed the relationship between parent report of a youth having an emotional, behavioral, or developmental problem (EBDP), their level of reported functional limitations, and parents' report of unmet mental health care needs and experience with cost-barriers to accessing needed healthcare services. Results indicate that, compared to all privately insured youth with special health care needs, parents of privately insured youth with EBDP are much more likely to report their child having unmet mental health care needs (OR 12.16; p < 0.001) and experiencing cost barriers to care (OR 2.37; p < 0.001). Parents of privately insured youth with EBDP with functional limitations are even more likely to report these concerns (Unmet Mental Health Needs: OR 17.09; p < 0.001; Cost Barriers: OR 5.77; p < 0.001). However, findings suggest that having public insurance is associated with reductions in the odds of having unmet needs for youth with SED by 50%. Public insurance and dual coverage is associated with reductions in the odds of encountering cost barriers to care by almost 50% for children with EBDP, and by more 50% for youth with EBDP and functional impairments.

Most Children With Medical Complexity Do Not Receive Care in Well-Functioning Health Care Systems

OBJECTIVES

To describe the access of children with medical complexity (CMC) to well-functioning health care systems. To examine the relationships between medical complexity status and this outcome and its component indicators.

PATIENTS AND METHODS

Secondary analysis of children in the National Survey of Children's Health combined 2016-2017 data set who received care in well-functioning health systems. Secondary outcomes included this measure's component indicators. The χ2 analyses were used to examine associations between child and family characteristics and the primary outcome. Adjusted multivariable logistic regression was used to examine relationships between medical complexity status and primary and secondary outcomes. Using these regression models, we examined the interaction between medical complexity status and household income.

RESULTS

CMC accounted for 1.6% of the weighted sample (n = 1.2 million children). Few CMC (7.6%) received care in a well-functioning health care system. CMC were significantly less likely than children with special health care needs (CSHCN) (odds ratio, 0.3) of meeting criteria for this primary outcome. Attainment rates for secondary outcomes (families feeling like partners in care; receives care within a medical home; received needed health care) were significantly lower among CMC than CSHCN. Family income was significantly associated with likelihood of meeting criteria for primary and secondary outcomes; however, the relationships between medical complexity status and our outcomes did not differ by income level.

CONCLUSIONS

CMC are less likely than other CSHCN to report receiving care in well-functioning health care systems at all income levels. Further efforts are necessary to better adapt current health care systems to meet the unique needs of CMC.

Follow-through care for high-risk infants during the COVID-19 pandemic: lessons learned from the Vermont Oxford Network

OBJECTIVE

The COVID-19 pandemic has altered the delivery of follow-up care for high-risk infants. We performed an audit to characterize programmatic responses in a quality improvement network.

STUDY DESIGN

We audited 43 North American-based follow-up programs of the Vermont Oxford Network Extremely Low Birth Weight Follow-up Study Group in October, 2020. Our electronic survey included yes/no, agree/disagree, and free text response items.

RESULT

The response rate was 67.4%. Most programs altered capacity and the timing, frequency, or content of clinical assessments. Most perceived practice changes compromised their ability to ascertain infants' medical and developmental needs. There was a rapid uptake of telemedicine services. Despite challenges with implementation, many endorsed improved connectedness with families.

CONCLUSION

Programs adapted rapidly to meet the needs of high-risk infants during the pandemic. Clinical operations, assessment procedures, and quality metrics will also need to evolve. Quality improvement study group collaboratives are well-positioned to coordinate such work.

Care Coordination Program for Children With Complex Chronic Conditions Discharged From a Rural Tertiary-Care Academic Medical Center

OBJECTIVES

Hospital discharge offers an opportunity to initiate coordination of follow-up care, preventing readmissions or emergency department (ED) recidivism. We evaluated how revisits and costs of care varied in a 12-month period between children in a care coordination program at our center (enrolled after hospital discharge with a tracheostomy or on a ventilator) and children with complex chronic condition discharges who were not enrolled.

METHODS

Children ages 1 to 17 years were retrospectively included if they had a hospital discharge in 2017 with an International Classification of Diseases, 10th Revision code meeting complex chronic condition criteria or if they were in active follow-up with the care coordination program. Revisits and total costs of care were compared over 2018 for included patients.

RESULTS

Seventy patients in the program were compared with 56 patients in the control group. On bivariate analysis, the median combined number of hospitalizations and ED visits in 2018 was lower among program participants (0 vs 1; P = .033), and program participation was associated with lower median total costs of care in 2018 ($700 vs $3200; P = .024). On multivariable analysis, care coordination program participation was associated with 59% fewer hospitalizations in 2018 (incidence rate ratio: 0.41; 95% confidence interval: 0.23 to 0.75; P = .004) but was not significantly associated with reduced ED visits or costs.

CONCLUSIONS

The care coordination program is a robust service spanning the continuum of patient care. We found program participation to be associated with reduced rehospitalization, which is an important driver of costs for children with medical complexity.

Differences in Reporting Child Health Needs and Status and Developmental Concerns between Mothers and Fathers: Findings from the National Survey of Children's Health

Nationally representative data of 140 000 children in 2-parent households showed that fathers were more likely than mothers to report that a child was in good health and less likely to report the presence of a specific health condition, special health care needs, or unmet health service needs.

Birth Weight Gradient in Parent-Reported Special Healthcare Needs among Children Born Preterm

OBJECTIVE

To characterize the association of birth weight with parent-reported special healthcare needs (SHCN) and unmet healthcare needs among children born prematurely.

STUDY DESIGN

We analyzed data from the 2016-2017 National Survey of Children's Health. Prematurity, birth weight, SHCN, and unmet healthcare needs were reported for one child per participating household. We analyzed children age 0-5 years, and classified birthweight among children born preterm as very low birth weight (VLBW, <1500 g), low birth weight (LBW, 1500-2500 g), and normal weight (NBW, >2500 g). Term-born NBW children were included as a reference group.

RESULTS

The analysis included 190 VLBW preterm, 688 LBW preterm, 884 NBW preterm, and 15 629 NBW term-born children. Weighted SHCN prevalence was 10%, and 1% had unmet healthcare needs. On multivariable analysis, children born preterm and VLBW had significantly higher odds of SHCN compared with NBW term-born children (OR, 9.8; 95% CI, 4.9-19.6). Preterm LBW and NBW preterm groups had smaller increases in SHCN odds (OR, 2.5 and OR, 1.6, respectively). The odds of unmet healthcare needs did not differ among the 4 study groups.

CONCLUSIONS

Among children under 5 years of age, preterm birth and VLBW are associated with very high likelihood of SHCN, compared with LBW/NBW preterm or NBW term-born children. However, requirements for additional health services in this group were adequately met, according to caregiver report.