The role of medical home in emergency department use for children with developmental disabilities in the United States

Association between Gaps in Care Coordination and Emergency Department Visits Among Children without Chronic Conditions or Special Needs

OBJECTIVE

Prior studies and have shown that gaps in care coordination (CC) increase the risk of emergency department (ED) visits among children with special healthcare needs. This study aims to determine if gaps in CC are associated with an increased risk of ED visits among children without special needs (non-CSHCN).

STUDY DESIGN

We conducted a cross-sectional study using the National Survey of Children's Health (2018-2019), representing children up to age 17. A "gap" in CC occurs if the adult proxy reported dissatisfaction with communication between providers or difficulty getting the help needed to coordinate care for the child. Using logistic regression models adjusting for age and sex, we measured the association between a gap in CC and 1 or more ED visits during the past 12 months overall and stratified by any special needs. Adjusted odds ratios (AOR) and 95% confidence intervals (95% CI) were calculated.

RESULTS

Between 2018 and 2019, 15% of respondents reported a gap in CC and 19.4% of children had at least one ED visit. Among non-CSHCN, these rates were 11% and 17%. In this population, a gap in CC was independently associated with an increased odds of ED use (AOR: 2.14; 95% CI 1.82, 2.52).

CONCLUSIONS FOR PRACTICE

Self-reported gaps in ambulatory CC were associated with increased odds of ED visits even among non-CSHCN children with minor illnesses, suggesting that providers need to be aware of potential pitfalls in CC for all children, and ensure that pertinent information is available where needed.

Unscheduled healthcare for children with intellectual disabilities: A systematic scoping review

Background

The provision of unscheduled healthcare for children with intellectual disability is less researched than that focused on hospital settings or for adult services. The aim of the scoping review was to map the evidence base in this area and identify areas for future study.

Method

A five‐stage scoping review framework was adopted. CINAHL, PubMed, SCOPUS, PsycINFO, Embase, ProQuest Dissertation & Theses and Google Scholar were searched. Studies published in English after 1/1/2000 were considered eligible for inclusion.

Results

A total of 3158 titles and abstracts were screened, 137 full‐text articles were reviewed, and 25 papers met the inclusion criteria. Descriptive themes focused on inequities, needs and experiences of families', poor GP training, and limitations of existing evidence.

Conclusion

Describing trends in healthcare utilisation by this population is valuable for monitoring quality of healthcare, however, addressing observed inequities will require approaches that recognise specific issues within the health system that result in inequities.

Infectious Diseases-Related Emergency Department Visits Among Non-Elderly Adults with Intellectual and Developmental Disabilities in the United States: Results from the National Emergency Department Sample, 2016

Emerging evidence on the disproportionate impact of COVID-19 on people with intellectual and developmental disabilities (IDD) points to the underlying risk and burden of infectious diseases (IDs) in this population. The objective of this study was to examine the risk of ID-related emergency department (ED) visits, subsequent hospitalizations, and hospital-based mortality during ID-related visits among adults with IDD compared to those without IDD. The authors conducted a retrospective study using data from the 2016 Nationwide Emergency Department Sample. The sample included 94,928 adults with IDD identified using ICD-10-CM codes, and age- and sex-matched 284,763 non-IDD adults in a 1:3 case-control ratio. A Poisson regression model was used to compare the risk of ID-related ED visits, subsequent hospitalizations, and hospital-based mortality during ID-related visits between adults with and without IDD. Covariates included sociodemographic and hospital characteristics. Results showed that adults with IDD are at a higher risk for ID-related ED visits, subsequent hospitalization, and mortality during ID-related ED visits compared to non-IDD adults. Adults with IDD continued to experience higher risks even after accounting for sociodemographic, hospital, and clinical characteristics. Septicemia and respiratory tract infections are the leading causes of ED visits, hospitalization, and mortality. This study found substantial disparities in ID-related ED visits, subsequent hospitalization, and mortality among the burdens for adults with IDD. These observations underscore the importance of integrated strategies to reduce ID-related morbidity among adults with IDD.

Patient-Centered Outcomes in an Interdisciplinary Clinic for Complex Children with Autism

OBJECTIVE

To compare the perspectives of caregivers of children with autism receiving care at the Neurobehavior Healthy Outcomes Medical Excellence (HOME) Program, an interdisciplinary clinic that provides primary care and behavioral/mental health services for patients with autism and other developmental disabilities, with those responding to the 2016 National Survey of Children's Health (NSCH). We focused on ratings related to shared decision-making, care coordination, family-centered care, and care within a medical home.

METHODS

We administered a subset of items from the 2016 NSCH to caregivers of children with autism enrolled in HOME and compared responses with the same items from a nationally representative group of caregivers of children with autism who completed the 2016 NSCH. We compared the proportions that reported receiving shared decision-making, care coordination, family-centered care, care within a medical home, and unmet needs among the 2 study groups using Poisson regression, controlling for age, sex, race/ethnicity, payor, autism severity, and intellectual disability (ID).

RESULTS

Compared with the NSCH cohort (n = 1151), children enrolled in HOME (n = 129) were older, more often female, had severe autism, and had co-occurring ID. Caregivers perceived that children receiving care within HOME more often received family-centered, coordinated care within a medical home compared with a national sample of children with autism. HOME enrollees also reported increased access to behavioral treatments and adult transition services with less financial burden compared with the national sample.

CONCLUSION

An interdisciplinary clinic model may best serve children with autism, especially those with higher severity symptoms and co-occurring conditions.

The Compounding Effect of Race/Ethnicity and Disability Status on Children's Health and Health Care by Geography in the United States

OBJECTIVE

The objective of this study was to examine the potential compounding effect of race/ethnicity, and disability status on children's health and health care, stratified by selected geographies.

METHODS

We used the 2011/2012 NSCH and the 2012 Boston Survey of Children's Health for our compounded disparity analysis. We used VanderWheel and Knol method to first predict combined risk ratios of race/ethnicity and disability and then compared them with the observed combined risk ratios.

RESULTS

We demonstrated that racial/ethnic minority children with disabilities experience additional disparities in health care access outcomes that are greater than the sum of the effects from either characteristic alone. Further, we demonstrate that disparities persist across all selected geographies irrespective of whether children lived in states or metropolitan cities with the best health care systems in the United States.

CONCLUSIONS

Despite reform efforts, our study demonstrates that racial/ethnic minority children with disabilities experience a double burden. Given the deleterious compounded disparities, public health and social service programs at all geographical levels should prioritize identifying participants that face this and tailor programs to meet their needs.

Impact of Medical Home on Health Care of Children With and Without Special Health Care Needs: Update from the 2016 National Survey of Children's Health

Objective The medical home has been promoted as an optimal model of health care delivery for children. The purpose of this study was to examine the association between having access to a medical home and the health care experiences of children with and without special health care needs (SHCN) in the United States. Methods We analyzed data from the 2016 National Survey of Children's Health. We modeled logistic regressions to assess associations of having access to a medical home with health care experiences for 11,392 CSHCN and 38,820 non-CSHCN. Results We found that not having access to a medical home was negatively associated with preventive medical and dental care visits, greater unmet medical and dental needs, and hospital emergency room visits. Additionally, not having access to a medical home was negatively associated with the physical and oral health among CSHCN and oral health among non-CSHCN. However, we found no significant association between improved physical health status and having access to a medical home among non-CSHCN. Conclusions Results from our analysis suggest that having access to a medical home remains key determinant of improved health care experiences by CSHCN and non-CSHCN in the United States. Our findings underscore the need to develop policies and implement a more concerted program to increase access to health care delivered under the medical home model for CSHCN and non-CSHCN. Policymakers, health care administrators and physician groups can use these findings to inform future policy decisions and service delivery reforms.

Risk Factors for Emergency Department Utilization Among Adolescents with Autism Spectrum Disorder

This study reaffirms our previous work documenting a higher number of Emergency Department (ED) visits by adolescent females with Autism Spectrum Disorder (ASD) as compared to adolescent males with ASD, as well as significantly more ED visits by older adolescents than younger adolescents with ASD. Combined externalizing and internalizing psychiatric co-morbidities as well as internalizing conditions alone predict a higher number of ED visits in this study. Illness severity as demonstrated by patterns of visits to primary care physicians and psychiatric referrals prior to ED visits and the prescription of two or more classes of psychotropic medications also predict higher number of ED visits. Finally, as expected, previous ED visits predict future ED visits. The identification of these factors may prove helpful in determining adequacy of current supports and resources for teens with ASD navigating the challenges of adolescence.

Towards translational health policy: Findings from a state evaluation of programs targeting children with special health care needs

PURPOSE

Current evidence-based research suggests that early evaluation, comprehensive care plans, and appropriate referrals for childhood and adolescent behavioral and development needs is critical for successful family-centered outcomes. The overall purpose of this study was to conduct an assessment of a state public health program that offers diagnostic evaluation and coordination for children with behavioral and developmental disorders in the state of Virginia (Child Development Center programs, or CDC). A secondary purpose was to provide translational policy and advocacy targets based on key findings.

DESIGN AND METHOD

The evaluation of the scope of services of the CDC programs was done using qualitative interviews with a focus group interview (n = 23), interviews from representatives from individual centers ( n = 5 centers), and descriptive quantitative data elements for the fiscal year 2015.

RESULTS

After conducting the state public health evaluation, several translational health policy priorities emerged, including: (a) the need for integrated data standards, (b) Lack of developmental pediatric workforce, particularly in rural sectors of the state, and (c) Need for enhanced program support for care coordination.

CONCLUSION

Academic nurse and public health partnerships can aid in translation from research to policy among vulnerable populations and assist in communication to key stakeholders and legislators for iterative action and reassessment.

See-Hear-Feel-Speak: A Protocol for Improving Outcomes in Emergency Department Interactions With Patients With Autism Spectrum Disorder

The presentation of children and adolescents with autism in the emergency department (ED) poses a unique set of challenges to clinicians and their teams, which have not yet been met. Children and adolescents with autism spectrum disorder (ASD) are more likely than their age and ethnically matched counterparts to visit both pediatric and general EDs and are more likely to use it for primary care complaints and dental care and to present for psychiatric concerns including suicidality. Despite the higher relative frequency, individuals with ASD demonstrate lower patient satisfaction, lower healthcare self-efficacy, and higher odds of unmet healthcare needs related to physical health, mental health, health maintenance, and vaccination. This can be ameliorated by simple strategies regarding communication, sensory and environmental modification, and distraction. After performing a literature review of existing evidence-based recommendations via PubMed as well as resources from autism advocacy and self-advocacy groups, we compiled a 4-step system: "See-Hear-Feel-Speak" an approach conducive to learning with the goal of enabling clinicians and their teams to facilitate patient-centered encounters with pediatric patients with ASD. The protocol meets the practicality requirements defined by published research.

Implementation of Practice Transformation: Patient Experience According to Practice Leaders

OBJECTIVE

Examine practice leaders' perceptions and experiences of how patient-centered medical home (PCMH) transformation improves patient experience.

SUBJECTS

Thirty-six interviews with lead physicians (n = 13), site clinic administrators (n = 13), and nurse supervisors (n = 10).

METHODS

Semi-structured interviews at 14 primary care practices within a large urban Federally Qualified Health Center (FQHC) delivery system to identify critical patient experience domains and mechanisms of change. Identified patient experience domains were compared with Consumer Assessment of Healthcare Providers and Systems (CAHPS) items.

RESULTS

We identified 28 patient experience domains improved by PCMH transformation, of which 22 are measured by CAHPS, and identified 24 mechanisms of change commonly reported by practice leaders during PCMH transformation.

CONCLUSIONS

PCMH practice transformation can improve patient experience. Most patient experience domains reported as improved during PCMH efforts are measured by CAHPS items. Practices would benefit from collecting specific information on staff behaviors related to teamwork, team-based communication, scheduling, emergency and inpatient follow-up, and referrals. All 3 types of practice leaders reported 4 main mechanisms of PCMH change that improved patient experience. Our findings provide guidance for practice leaders on which strategies of PCMH practice transformation lead to specific improvements in patient experience measures. Further research is needed on the relationship between PCMH changes and changes in CAHPS patient experience scores.

A Profile on Emergency Department Utilization in Adolescents and Young Adults with Autism Spectrum Disorders

There has been an increase in utilization of the Emergency Department (ED) in individuals with autism spectrum disorder (ASD) which may reflect a deficit of services (Green et al., Journal of the American Academy of Child and Adolescent Psychiatry 40(3):325-332, 2001; Gurney et al., Archives of Pediatric and Adolescent Medicine 160:825-830, 2006; Leichtman et al., American Journal of Orthopsyhciatry 72(2):227-235, 2001). The current study examined the rates of ED utilization between 2005 and 2013 in ASD youth 12- to 21-years-old. Adolescents with ASD accessed ED services four times as often as adolescents without ASD. Older adolescents and those living in rural areas showed a significant increase in ED visits over time. Post hoc analysis revealed increased ED utilization for females and behavioral health ED services over time. Better access to and greater understanding of services for adolescents with ASD is a critical need.

Comparative Effectiveness of Usual Source of Care Approaches to Improve End-of-Life Outcomes for Children With Intellectual Disability

CONTEXT

Children with intellectual disability (ID) are at risk for adverse end-of-life outcomes including high emergency room utilization and hospital readmissions, along with low hospice enrollment.

OBJECTIVES

The objective of this study was to compare the effectiveness of usual source of care approaches to improve end-of-life outcomes for children with ID.

METHODS

We used longitudinal California Medicaid claims data. Children were included who were 21 years with fee-for-service Medicaid claims, died between January 1, 2007, and December 31, 2010, and had a moderate-to-profound ID diagnosis. End-of-life outcomes (i.e., hospice enrollment, emergency room utilization, hospital readmissions) were measured via claims data. Our treatments were usual source of care (USC) only vs. usual source of care plus targeted case management (USC plus TCM). Using instrumental variable analysis, we compared the effectiveness of treatments on end-of-life outcomes.

RESULTS

Ten percent of children with ID enrolled in hospice, 73% used the emergency room, and 20% had three or more hospital admissions in their last year of life. USC plus TCM relative to USC only had no effect on hospice enrollment; however, it significantly reduced the probability of emergency room utilization (B = -1.29, P < 0.05) and hospital readmissions (B = -1.71, P < 0.001).

CONCLUSIONS

Our findings demonstrated that USC plus TCM was more effective at improving end-of-life outcomes for children with ID. Further study of the extent of UCS and TCM involvement in reducing emergency room utilization and hospital readmissions at end of life is needed.

Emergency medical services providers' perspective of end-of-life decision making for people with intellectual disabilities

BACKGROUND

Emergency medical services (EMS) providers are often called to rapidly determine and act upon patients' wishes for end-of-life care. People with intellectual disabilities are living increasingly longer with complex conditions leading to international calls for person-centred advance care planning. Yet, best estimates suggest that very few people with intellectual disabilities document their wishes.

METHODS

This exploratory-descriptive study incorporated mixed methods to analyse data collected consecutively (surveys, n = 239; interviews, n = 48) with EMS providers from five agencies. Data were subjected to a sequential quantitative-qualitative analysis applying a critical discourse analysis framework.

RESULTS

Findings indicate that 62.7% had treated a person with intellectual disability who had medical orders directing end-of-life care. Three themes (provider familiarity, organizational processes, sociocultural context) offer insights about how medical orders inform EMS providers during calls involving people with intellectual disabilities.

CONCLUSION

Multiple contexts influence how wishes are documented and care provided to people with intellectual disabilities near life's end.

Impact of Chronic Conditions on Emergency Department Visits of Children Using Medicaid

OBJECTIVE

To assess the impact of chronic conditions on children's emergency department (ED) use.

STUDY DESIGN

Retrospective analysis of 1 850 027 ED visits in 2010 by 3 250 383 children ages 1-21 years continuously enrolled in Medicaid from 10 states included in the Truven Marketscan Medicaid Database. The main outcome was the annual ED visit rate not resulting in hospitalization per 1000 enrollees. We compared rates by enrollees' characteristics, including type and number of chronic conditions, and medical technology (eg, gastrostomy, tracheostomy), using Poisson regression. To assess chronic conditions, we used the Agency for Healthcare Research and Quality's Chronic Condition Indicator system, assigning chronic conditions with ED visit rates ≥75th percentile as having the "highest" visit rates.

RESULTS

The overall annual ED visit rate was 569 per 1000 enrollees. As the number of the children's chronic conditions increased from 0 to ≥3, visit rates increased by 180% (from 376 to 1053 per 1000 enrollees, P < .001). Rates were 174% higher in children assisted with vs without medical technology (1546 vs 565, P < .001). Sickle cell anemia, epilepsy, and asthma were among the chronic conditions associated with the highest ED visit rates (all ≥1003 per 1000 enrollees).

CONCLUSIONS

The highest ED visit rates resulting in discharge to home occurred in children with multiple chronic conditions, technology assistance, and specific conditions such as sickle cell anemia. Future studies should assess the preventability of ED visits in these populations and identify opportunities for reducing their ED use.