An innovative health-care delivery model for children with medical complexity

Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis

STUDY OBJECTIVES

To examine the risk of increased health care utilization (HU) linked to individual sleep disorders in children with chronic medical conditions.

METHODS

Medicaid claims data from a cohort of 16,325 children enrolled in the Coordinated Healthcare for Complex Kids (CHECK) project were used. Sleep disorders and chronic medical conditions were identified using International Classification of Diseases, Ninth, and 10th Revision, codes. Three HU groups were identified based on participants' prior hospitalizations and emergency department (ED) visits in the 12 months prior to enrollment: low (no hospitalization or ED visit), medium (1-2 hospitalizations or 1-3 ED visits), and high (≥ 3 hospitalizations or ≥ 4 ED visits). The odds of being in an increased HU group associated with specific sleep disorders after controlling for confounding factors were examined.

RESULTS

Children with chronic medical conditions and any sleep disorder had nearly twice the odds (odds ratio = 1.83; 95% confidence interval: 1.67-2.01) of being in an increased HU group compared with those without a sleep disorder. The odds of being in the increased HU group varied among sleep disorders. Only sleep-disordered breathing (odds ratio = 1.51; 95% confidence interval : 1.17-1.95), insomnia (odds ratio = 1.46; 95% confidence interval : 1.06-2.02), and circadian rhythm sleep disorder (odds ratio = 2.45; 95% confidence interval : 1.07-5.64) increased those odds. Younger age and being White were also linked to increased HU.

CONCLUSIONS

Sleep disorders are associated with increased risk of heightened HU (ED visits and/or hospitalizations) in children with chronic medical conditions. This risk varies by specific sleep disorders. These findings indicate the need for careful evaluation and management of sleep disorders in this high-risk cohort.

CITATION

Adavadkar PA, Brooks L, Pappalardo AA, Schwartz A, Rasinski K, Martin MA. Association between sleep disorders and health care utilization in children with chronic medical conditions: a Medicaid claims data analysis. J Clin Sleep Med. 2024;20(4):595-601.

BEhavioral Health Stratified Treatment (B.E.S.T.) to optimize transition to adulthood for youth with intellectual and/or developmental disabilities

Youth with intellectual and/or developmental disabilities (IDD) often struggle with depression and anxiety, which adversely impacts transition to adulthood. Integrated behavioral health care coordination, wherein care coordinators and behavioral health specialists collaborate to provide systematic, cost-effective, patient-centered care, is a promising strategy to improve access to behavioral health services and address factors that impact transition to adulthood, including depression/anxiety symptoms. Current care coordination models (e.g., Title V Maternal and Child Health Bureau [MCHB]) do not include behavioral health services. The CHECK (Coordinated HealthCarE for Complex Kids) mental health model, hereby refined and renamed BEhavioral Health Stratified Treatment (B.E.S.T.), is a behavioral health intervention delivery program designed for integration into care coordination programs. This study aims to determine whether an integrated behavioral health care coordination strategy (i.e., MCHB care coordination plus B.E.S.T.) would be more acceptable and lead to better youth health and transition outcomes, relative to standard care coordination (i.e., MCHB care coordination alone). Results would guide future investment in improving outcomes for youth with IDD. This study is a two-arm randomized clinical trial of 780 transition-aged youth with IDD (13-20 years) to evaluate the comparable efficacy of MCHB Care Coordination alone vs. MCHB Care Coordination plus B.E.S.T. on the following outcomes: 1) decreased symptoms and episodes of depression and anxiety over time; 2) improved health behaviors, adaptive functioning and health related quality of life; 3) increased health care transition (HCT) readiness; and 4) improved engagement and satisfaction with care coordination among stakeholders.

Provision of care for children with medical complexity in tertiary hospitals in England: qualitative interviews with health professionals

BACKGROUND

Due to medical and technological advancements, children with medical complexity are a growing population. Although previous research has identified models of care and experiences when caring for this population, the majority are the USA or Canadian based. Therefore, the aim was to identify models of care for children with medical complexity and barriers and facilitators to delivering high-quality care for this population from a 'free at point of care' national health service.

METHOD

Qualitative semistructured interviews were conducted with hospital clinicians across England and analysed using a thematic framework approach.

RESULTS

Thirty-seven clinicians from 11 hospital sites were interviewed. In 6 of the hospital sites, there were 14 services identified. Majority of services had a variety of components, some shared and some unique to the individual service. Clinicians faced barriers and facilitators when caring for this population as demonstrated across five categories.

CONCLUSIONS

There is limited guidance and evidence on the most effective and efficient models for providing care for this population. It is not possible to determine what a service should look like as there is no consensus on the most appropriate model of care as shown in this study. Due to their complex needs, this population require coordination to ensure high standards of care. However, this was not always possible as clinicians faced barriers such as time constraints, silo thinking and a lack of available housing.

The Effect of Neighborhood Disorganization on Care Engagement Among Children With Chronic Conditions Living in a Large Urban City

Neighborhood context plays an important role in producing and reproducing current patterns of health disparity. In particular, neighborhood disorganization affects how people engage in health care. We examined the effect of living in highly disorganized neighborhoods on care engagement, using data from the Coordinated Healthcare for Complex Kids (CHECK) program, which is a care delivery model for children with chronic conditions on Medicaid in Chicago. We retrieved demographic data from the US Census Bureau and crime data from the Chicago Police Department to estimate neighborhood-level social disorganization for the CHECK enrollees. A total of 6458 children enrolled in the CHECK between 2014 and 2017 were included in the analysis. Families living in the most disorganized neighborhoods, compared with areas with lower levels of disorganization, were less likely to engage in CHECK. Black families were less likely than Hispanic families to be engaged in the CHECK program. We discuss potential mechanisms through which disorganization affects care engagement. Understanding neighborhood context, including social disorganization, is key to developing more effective comprehensive care models.

CHECK: Multi-level Real-World Pediatric Asthma Care Coordination: Results and Lessons Learned

OBJECTIVE

Because asthma health disparities in children remain common, innovative approaches to obtain asthma health equity are essential. Comprehensive care coordination programs may address the social determinants of health that influence these disparities. This analysis aims to ascertain if receipt of Coordination of Healthcare for Complex Kids (CHECK) program services was associated with changes in school absence, cost, healthcare utilization, and controller prescription in children with asthma.

METHODS

The CHECK program ran from December 1^st, 2014 through August 31^st, 2017. Engagement with Community Health Workers (CHW) was rolling and targeted based on risk level (low, medium or high determined by healthcare utilization). This analysis included school-aged children with asthma (n = 2,629) and sufficient Chicago Public Schools attendance data (n = 430).

RESULTS

Children engaged in CHECK were more likely to be female (p = 0.046) and to identify as Black and/or Hispanic/Latino than enrolled-only children. School absence was not different between the groups. Average total cost for engaged children was 21.3% more than enrolled-only children the first year (p = 0.027) but did not differ by the second year (p = 0.948). At baseline, 68.1% of the cohort had at least one ED visit 12-months prior to CHECK, this reduced to 49.5% post-1 and 41.9% post-2. Engaged children were 21% more likely to visit an ED (p = 0.010) and 40% more likely to have a controller.

CONCLUSIONS

CHECK program receipt was associated with reduced costs and improved healthcare utilization, and controller prescriptions. School attendance did not change. The CHECK model offers potential pathways to support low-income children with asthma.

Rates of diagnoses of sleep disorders in children with chronic medical conditions

STUDY OBJECTIVES

This investigation examines sleep disorder (SD) diagnoses in a large population of children and adolescents with chronic medical conditions (CMCs). Little is known about SD diagnoses in this population. The large population used in this study allowed examination of SD rates by CMC type and demographics.

METHODS

Data were from the Coordinated Health Care for Complex Kids (CHECK) project designed for Medicaid-funded children and adolescents with at least one CMC from a large metropolitan area. The study population (N=16,609) was limited to children and adolescents, 0 to 18 years of age. SD and CMC diagnoses were obtained from Medicaid claims data.

RESULTS

Fourteen percent of the population (mean age of 9.1 years [SD= 5.2]; 35.8% African American (AA); 56.4% male; 77 with more than one CMC) received a sleep disorder diagnosis. The most frequent diagnosis was SDB (11.2%), followed by nocturnal enuresis (1.2%), and insomnia (1%). SDs were diagnosed more frequently in those with multiple CMCs than in those with one CMC (19.7% vs. 5.8%; p <0.001). Insomnia rates in Hispanic/Latinx (1.2%) and AA (0.8%) children and adolescents were significantly lower (both p<0.001) than in Caucasians (3.5%). Odds of receiving a sleep diagnosis varied among CMCs.

CONCLUSIONS

Our analysis of Medicaid claims data of a large urban cohort offers detailed information about the rates of sleep diagnoses and suggests under-diagnosis of SDs in this vulnerable, high-risk, primarily ethnic minority population. Under-recognition of sleep disorders have short- and long-term health and economic consequences. Study results may help clinicians implement appropriate SD screening and management for children and adolescents with CMCs.

Health status, healthcare, and access in children with long-term medication use and difficulties with emotion, concentration, and behavior

PROBLEM

Children with chronic conditions often have difficulties with emotions, concentration, and behaviors (ECB) and are not recognized and treated adequately. In this paper, long-term medication use (LTM) was adopted as a proxy for chronic illness due to the lack of consistent and standardized diagnostic criteria for chronic illnesses in children.

METHODS

Children (8-12 years) were selected from the California Health Interview Survey (2017) based on: (1) households with children (<12 years), (2) parent/adult caregivers report about child's health indicating "yes" to, (3) "does your child require prescription medicine for a health condition that has lasted or is expected to last at least 12 months or more," and (4) "difficulties with ECB in past 6 months."

FINDINGS

A total of 1600 children were included by the CHIS data set, and children whose parental report had met the selection criteria were children with LTM (n = 144; 7.4 ± 2.9 years), ECB (n = 233; 8.16 ± 2.14), and both LTM + ECB (n = 62; 8.61 ± 1.81). Children with LTM+ ECB were Caucasian (56.4%), Hispanic (19.3%), and males (64.5%). Children with both LTM + ECB had two to three (33.87%) or at least four (53.2%) physician visits, and/or receiving special therapy (45.1%). Children with LTM had prescription delays (n = 144; 5.6%) and were not able to get medical care due to lack of insurance (n = 144; 6.9%). The majority of the children with LTM (54.2%) and LTM + ECB (43.5%) had parental employment-based insurance. More children that have both LTM and ECB (48.4%) than children with LTM, No ECB (32.9%) were on Medi-Cal/Medicaid.

CONCLUSION

Children with LTM need further evaluation for difficulties with ECB. Future studies are required to examine health status, healthcare use, and access for children with LTM and ECB.

Patient experience surveys for children's community health services: A scoping review

Patient experience surveys have a user focus and measure the quality of person-centered health care for hospital inpatients and consumers of community health services, providing a governance process to evaluate the quality of care and to action improvement. Experience of care has been described as effective communication, respect and dignity, and emotional support. Measurement criteria for these domains are not standardized, leading to inconsistent reporting of patient experience. The objective of this scoping review was to synthesize evidence for measuring experience of care in children's community health services using the Joanna Briggs Institute framework for scoping review method. Three parent-reported surveys met the inclusion criteria, and 50 survey items were assessed by expert reviewers for fit to domains of healthcare experience. Conceptual domains of parent experience in children's community health services included respect and dignity, effective communication, and emotional support. A gap was identified, in that few items in identified surveys measured emotional support. This contribution will promote consistent reporting of healthcare experience, informing policy and practice for person-centered health care.

A National Mental Health Profile of Parents of Children With Medical Complexity

OBJECTIVES

The mental health of parents of children with medical complexity (CMC) is poorly understood, yet it drives child and family health outcomes. For parents of CMC, compared with parents of noncomplex children with special health care needs (CSHCN) and children without special health care needs (non-CSHCN), we examined self-reported mental health, knowledge of community sources for help, and emotional support.

METHODS

Using parent-reported data from the combined 2016-2017 National Survey of Children's Health, we divided the population into 3 groups: households with CMC, noncomplex CSHCN, and non-CSHCN. We compared these groups regarding the following: (1) parents' risks for poor or fair mental health and knowledge of where to go for community help and (2) parent-reported sources of emotional support.

RESULTS

Of 63 955 588 parent-child dyads (weighted from a sample of 65 204), parents of CMC had greater adjusted odds of reporting poor or fair mental health compared with parents of noncomplex CSHCN (adjusted odds ratio [aOR] 2.0; 95% confidence interval [CI] 1.1-3.8) and non-CSHCN (aOR 4.6; 95% CI 2.5-8.6). Parents of CMC had greater odds of not knowing where to find community help compared with parents of noncomplex CSHCN (aOR 2.1; 95% CI 1.4-3.1) and non-CSHCN (aOR 2.9; 95% CI 2.0-4.3). However, parents of CMC were most likely to report receiving emotional support from health care providers and advocacy groups (P < .001).

CONCLUSIONS

Among all parents, those with CMC were at the highest risk to report suboptimal mental health. They more often reported that they do not know where to find community help, but they did say that they receive emotional support from health care providers and advocacy groups. Future researchers should identify ways to directly support the emotional wellness of parents of CMC.

African American Children Are More Likely to Be Allergic to Shellfish and Finfish: Findings from FORWARD, a Multisite Cohort Study

BACKGROUND

Despite major differences in health profiles and rates of health care utilization between African American and White children with food allergy (FA), the detailed phenotypic variables that can potentially impact these outcomes have not been thoroughly studied.

OBJECTIVE

We aimed to characterize phenotypic differences such as allergies to different foods and allergic comorbidities between African American and White children with FA enrolled in the Food Allergy Outcomes Related to White and African American Racial Differences study.

METHODS

Our active, prospective, multicenter cohort study is currently enrolling African American and White children aged 0 to 12 years diagnosed with FA and followed by allergy/immunology clinics at 4 urban tertiary centers in the United States. To evaluate associations between race and phenotypic variables, we used multivariable logistic regression, adjusting for important demographic and confounding factors, as well as potential household clustering.

RESULTS

As of May 2020, there were 239 African Americans and 425 Whites with complete intake information enrolled in the study. In comparison with Whites, we found that African Americans had significantly higher adjusted odds of allergy to finfish (odds ratio [OR]: 2.54, P < .01) and shellfish (OR: 3.10, P < .001). African Americans also had higher adjusted odds of asthma than Whites (asthma prevalence of 60.5% in African Americans and 27.2% in Whites; OR: 2.70, P < .001). In addition, shellfish allergy was associated with asthma, after controlling for race.

CONCLUSION

Among a diverse cohort of children with physician-diagnosed FA, we observed that African American children had higher odds of allergy to shellfish and finfish, and higher rates of asthma. Interestingly, having asthma was independently associated with allergy to shellfish, after controlling for race.

Trends in School Attendance for Low-Income Children with Chronic Health Conditions: Results from a Randomized Controlled Trial

BACKGROUND

In this study, we aimed to determine how school attendance changed over time for children on Medicaid with chronic health conditions enrolled in a comprehensive care coordination program called Coordinated HEalthcare for Complex Kids (CHECK).

METHODS

Medicaid beneficiaries from one managed care organization were randomized into 2 arms: CHECK program services or usual care. The final sample was 1322.

RESULTS

The mean age was 10.9 (SD = 3.7) years old and children were mostly non-Hispanic Black (62.6%) or Hispanic (34.9%). The median school attendance at baseline was 94.9% (IQR 88.9, 97.9); over one-fourth of children (28.4%) were chronically absent. School attendance was not associated with race/ethnicity, risk level, and health condition. In a model including a significant time/grade interaction, school attendance increased over time for children in pre-kindergarten (OR = 1.52, 95% CI: 1.38, 1.68; p < .001) and kindergarten to 5th grade (OR = 1.21, 95% CI: 1.17, 1.26; p < .001), and decreased for children in 6th to 8th grade (OR = 0.80, 95% CI: 0.77, 0.83; p < .001). No differences were seen in school attendance or chronic absenteeism associated with enrollment in the CHECK program.

CONCLUSIONS

School attendance improved for most of the low-income children with chronic health conditions in our cohort, except for children in middle school.

Effect of physical exercise on the functional capacity of children and adolescents submitted to transplantation of hematopoietic stem cells-A systematic review with meta-analysis

Previous studies have shown beneficial effects of physical exercise (PE) in adults submitted to hematopoietic stem cell transplantation (HSCT). Conduct a systematic review about the effects of PE on the functional capacity of children and adolescents submitted to HSCT. The studies were searched in the databases MEDLINE (via PubMed), Central Register of Controlled Trials (Cochrane CENTRAL), EMBASE, LILACS, and Evidence Database in Physical Therapy (PEDro) (CRD42018080093). Two independent reviewers performed the article selection, data extraction, and methodological quality assessment. Randomized and nonrandomized clinical trials comparing PE with usual treatment in children and adolescents aged 3-18 years were included. The risk of bias was assessed using the Cochrane Collaboration tool and ROBINS-I tool, and the overall quality of the evidence was determined by the GRADE system. We included three studies with 91 patients. PE improved the functional capacity assessed by the timed up and down stairs test (MD -1.23 [95% CI, 2.27 to -.20, I2 = 0%]), but there was no significant effect in the six-minute walk test (MD 44.63 [95% CI, -20.86 to 110.13, I2 = 83%]). The benefits regarding quality of life and peripheral muscle strength of these individuals were not clearly demonstrated, but positive responses were observed in relation to the analyzed data. None of the studies evaluated the fatigue. The limitations found were the high heterogeneity between studies, as well as the sample size and the low methodological rigor. PE might be favorable to improve the functional capacity of children and adolescents treated with HSCT. However, further studies are needed to clarify the best PE program.

Lessons Learned, Best Practices: Care Coordination for Children with Medical Complexity

Although care coordination has long been established in the health care system in the United States, too often it may compete or work at cross purposes with care teams serving patients and families. Care coordination is a team sport that requires strong clinician-family partnerships as well as adequate time and resources to be done effectively. We incorporate the latest literature to offer clarity for identifying, coordinating, and funding care for children with medical complexity (CMC), the most medically fragile, high-cost subpopulation of children and youth with special health care needs. Algorithms for identifying CMC exist. Calculation of the cost of care for CMC is confounded by cost shifting to families and the variable course of illness and aging in this heterogeneous population. Multiple studies of different sizes have reported similar care coordination team structure, staffing ratios, and cost ranges. We describe models for funding this work and how they can be tailored to individual practice environments. [Pediatr Ann. 2020;49(11):e457-e466.].

Work-Sampling Study of an Innovative Care Coordination Program Aimed at Children With Chronic Health Conditions

PURPOSE OF STUDY

To estimate time allocation and labor cost for care coordinators (CCs), community health workers (CHWs), and mental health workers (MHWs) to conduct care coordination tasks in a pediatric care coordination program.

PRIMARY PRACTICE SETTING

A public tertiary academic medical center in Chicago, IL.

METHODOLOGY AND SAMPLE

A work-sampling study was conducted using a text message-based survey on 5 CCs, 20 CHWs, and 4 MHWs who volunteered to participate. Workers were randomly sampled within working hours to collect information on who was the subject of interaction and what service was being delivered over a 6-month period. Time allocation of workers to different subjects and services was summarized using descriptive statistics.

RESULTS

Care coordinators allocated 41% of their time to managing CHW teams. Community health workers allocated 37% of time providing services directly to children and 26% to the parent/caregiver. Mental health workers allocated 16% of time providing services to children and 29% to the parent/caregiver. The care coordination program serviced 5,965 patients, with a total annual labor cost of $1,455,353.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Community health workers spent the majority of time working with patients and their families to conduct assessments. Mental health workers primarily addressed children's needs through their caregivers. Care coordinators primarily supported CHWs in coordinating care. Results may be used to inform development of such programs by determining services most often utilized, and labor cost may be used to inform program implementation and reimbursement.

Pediatric complex care and surgery comanagement: Preparation for spinal fusion

The aim of this study is to assess the impact of preoperative comanagement with complex care pediatricians (CCP) on children with neuromuscular scoliosis undergoing spinal fusion. We performed chart review of 79 children aged 5-21 years undergoing spinal fusion 1/2014-6/2016 at a children's hospital, with abstraction of clinical documentation from preoperative health evaluations performed regularly by anesthesiologists and irregularly by a CCP. Preoperative referrals to specialists, labs, tests, and care plans needed last minute for surgical clearance were measured. The mean age at surgery was 14 (SD 3) years; cerebral palsy (64%) was the most common neuromuscular condition. Thirty-nine children (49%) had a preoperative CCP evaluation a median 63 days (interquartile range (IQR) 33-156) before the preanesthesia visit. Children with CCP evaluation had more organ systems affected by coexisting conditions than children without an evaluation (median 11 (IQR 9-12) vs. 8 (IQR 5-11); p < .001). The rate of last-minute care coordination activities required for surgical clearance was lower for children with versus without CCP evaluation (1.8 vs. 3.6). A lower percentage of children with CCP evaluation required last-minute development of new preoperative plans (26% vs. 50%, p = .002). Children with CCP involvement were better prepared for surgery, requiring fewer last-minute care coordination activities for surgical clearance.

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.

Implementing a Pediatric Perioperative Surgical Home Integrated Care Coordination Pathway for Laryngeal Cleft Repair

BACKGROUND

The Pediatric Perioperative Surgical Home (PPSH) model is an integrative care model designed to provide better patient care and value by shifting focus from the patient encounter level to the overarching surgical episode of care. So far, no PPSH model has targeted a complex airway disorder. It was hypothesized that the development of a PPSH for laryngeal cleft repair would reduce the high rates of postoperative resource utilization observed in this population.

METHODS

Institutional review board approval was obtained for the purpose of data collection and analysis. A multidisciplinary team of anesthesiologists, surgeons, nursing staff, information technology specialists, and finance administrators was gathered during the PPSH development phase. Standardized perioperative (preoperative, intraoperative, and postoperative) protocols were developed, with a focus on preoperative risk stratification. Patients presenting before surgery with ≥1 predefined medical comorbidity were triaged to the intensive care unit (ICU) postoperatively, while patients without severe systemic disease were triaged to a lower-acuity floor for overnight observation. The success of the PPSH protocol was defined by quality outcome and value measurements.

RESULTS

The PPSH initiative included 120 patients, and the pre-PPSH period included 115 patients who underwent laryngeal cleft repair before implementation of the new process. Patients in the pre-PPSH period were reviewed and classified as ICU candidates or lower acuity floor candidates had they presented in the post-PPSH period. Among the 79 patients in the pre-PPSH period who were identified as candidates for the lower-acuity floor transfer, 70 patients (89%) were transferred to the ICU (P < .001). Retrospective analysis concluded that 143 ICU bedded days could have been avoided in the pre-PPSH group by using PPSH risk stratification. Surgery duration (P = .034) and hospital length of stay (P = .015) were found to be slightly longer in the group of pre-PPSH observation unit candidates. Rates of 30-day unplanned readmissions to the hospital were not associated with the new PPSH initiative (P = .093). No patients in either group experienced emergent postoperative intubation or other expected complications. Total hospital costs were not lower for PPSH observation unit patients as compared to pre-PPSH observation unit candidates (difference = 8%; 95% confidence interval, -7% to 23%).

CONCLUSIONS

A well-defined preoperative screening protocol for patients undergoing laryngeal cleft repair can reduce postoperative ICU utilization without affecting patient safety. Further research is needed to see if these findings are applicable to other complex airway surgeries.

Exploring Racial Disparities in Mental Health Diagnoses and Neighborhood Disorganization Among an Urban Cohort of Children and Adolescents with Chronic Medical Conditions

Objective: This article describes the demographic distribution of, and association between, neighborhood disorganization and mental health diagnosis by race in a large cohort of urban children with chronic medical conditions. Methods: Data for this study were from Coordinated Healthcare for Complex Kids (CHECK), a health care demonstration project funded by the Center for Medicare and Medicaid Innovation. We conducted regression analyses to examine the relationship between neighborhood disorganization and mental health diagnosis among 6,458 children enrolled in CHECK. Results: The most common mental health diagnoses were mood disorders (8.6%), Attention-Deficit/Hyperactivity Disorder (7.4%), conduct disorders (6.1%), and anxiety disorders (4.8%). Black children had the highest neighborhood disorganization scores compared with other racial/ethnic categories. However, Black children had the lowest proportion of mental health diagnoses. Lower neighborhood disorganization was associated with having a mental health diagnosis; however, when adding race/ethnicity to the model, neighborhood disorganization no longer was significant. Conclusions: Level of neighborhood disorganization was highly correlated with racial/ethnic composition of the neighborhoods, and Black children disproportionately resided in highly disorganized neighborhoods compared with other groups. Neighborhood disorganization may not have sufficient variability within the racial/ethnic categories, which may explain the absence of an interaction between race/ethnicity and mental health diagnosis.

A multivariable analysis of childhood psychosocial behaviour and household functionality

BACKGROUND

Social determinants of health play a vital role in population health. Awareness of household social factors and their impact on health can help health professionals to provide effective strategies in health promotion, especially for children and adolescents showing signs of psychosocial dysfunction. The objective of this study was to explore the association between parents' perceptions of the psychosocial behaviour of their children and the functionality of their household.

METHODS

This cohort study analysed data from the Coordinated Health Care for Complex Kids programme. The sample included 293 parents of children aged 4-17 years with chronic conditions, and from urban, low-income families. Psychosocial behaviour of the child was measured using the Pediatric Symptom Checklist (PSC-17), which included subscales for internal, external, and attention symptoms. Household functionality was measured using the Confusion, Hubbub, and Order Scale. Responses to both assessments were scored in a standard manner.

RESULTS

There was a significant association between parents' perceptions of the psychosocial behaviour of their children and the functionality of the home environment. The mean Confusion, Hubbub, and Order Scale scores in the home environment improved from baseline to the first reassessment (the period between the two assessments ranged from 4 to 8 months). Additionally, positive PSC-17 screening results of the children decreased by 11% in the first reassessment. The odds of having a positive PSC-17 screening result also decreased in the first reassessment after receiving interventions.

CONCLUSION

The association between psychosocial dysfunction and household functionality indicates the importance of family-centred care and taking the home environment into consideration when administering health services to low-income children with chronic conditions. This study brings attention to the more hidden factors that influence child mental health, which must be addressed to improve care delivery and child health outcomes.

Health care utilization and spending among privately insured children with medical complexity

Children with medical complexity have high health service utilization and health expenditures that can impose significant financial burdens. This study examined these issues for families with children enrolled in US private health plans. Using IBM Watson/Truven Analytics℠ MarketScan® commercial claims and encounters data (2012-2014), we analyzed through regression models, the differences in health care utilization and spending of disaggregated health care services by health plan types and children's medical complexity levels. Children in consumer-driven and high-deductible plans had much higher out-of-pocket spending and cost shares than those in health maintenance organizations and preferred provider organizations (PPOs). Children with complex chronic conditions had higher service utilization and out-of-pocket expenditures while having lower cost shares on various categories of services than those without any chronic condition. Compared to families covered by PPOs, those with high-deductible or consumer-driven plans were 2.7 and 1.7 times more likely to spend over US$1000 out of pocket on their children's medical care, respectively. Families with higher complexity levels were more likely to experience financial burdens from expenditures on children's medical services. In conclusion, policymakers and families with children need to be cognizant of the significant financial burdens that can arise from children's complex medical needs and health plan demand-side cost sharing.

A Two-Way Interactive Text Messaging Application for Low-Income Patients with Chronic Medical Conditions: Design-Thinking Development Approach

Background

Two-way interactive text messaging between patient and community health workers (CHWs) through mobile phone SMS (short message service) text messaging is a form of digital health that can potentially enhance patient engagement in young adults and families that have a child with chronic medical conditions such as diabetes mellitus, sickle cell disease, and asthma. These patients have complex needs, and a user-centered way can be useful for designing a tool to address their needs.

Objective

The aim of this study was to utilize the user-centered approach of design thinking to develop a two-way interactive communication SMS text messaging tool for communication between patients or caregivers and CHWs.

Methods

We applied a design thinking methodology for development of the SMS text messaging tool. We collected qualitative data from 127 patients/caregivers and 13 CHWs, health care professionals, and experts. In total, 4 iterative phases were used to design the final prototype.

Results

The design thinking process led to the final SMS text messaging tool that was transformed from a one-dimensional, template-driven prototype (phases 1 and 2) into a dynamic, interactive, and individually tailored tool (phases 3 and 4). The individualized components consider social factors that influence patients’ ability to engage such as transportation issues and appointment reminders. SMS text messaging components also include operational factors to support staff such as patient contact lists, SMS text messaging templates, and technology chat support.

Conclusions

Design thinking can develop a tool to meet the engagement needs of patients with complex health care needs and be user-friendly for health care staff.

Compassion and connectedness as motivational drivers in the care of children with medical complexity

Employing a cross-sectional qualitative descriptive design, using individual, semi-structured interviews collected from primary care and specialty clinicians who routinely care for children with medical complexity (CMC) in a largely rural area in central Virginia, this study aimed to better understand the current state of care, the motivations, and barriers for expansion of care for CMC in a semi-rural academic hospital center. Five themes emerged describing the current practice of the participants: (1) complexities of care, (2) compassion and empathy for families, (3) limited resources, (4) essential nature of coordination and teamwork, and (5) proximity to care. Each of the five themes that emerged from our interviews present both challenges and rewards. The theme of compassion for families of CMC is seen as a key potential motivational driver for expansion and reorganization of clinical care for CMC.

Chicago Public School nurses examine barriers to school asthma care coordination

OBJECTIVE/DESIGN

Well documented asthma disparities in Chicago pose a continual challenge for the Chicago Public Schools (CPS). Coordinated Healthcare for Complex Kids (CHECK) is a health care demonstration project funded by a Centers for Medicare and Medicaid Services Health Care Innovation Award. A collaborative partnership was formed between CHECK and CPS. With CHECK support, CPS administered a survey to 160 nurses to understand the asthma problems nurses perceived and interest in intervention.

RESULTS

Seventy-five per cent (n = 120) completed the survey. While asthma was the top diagnosis managed by 95%, 72% reported gaps in asthma understanding. Appropriate communication between school nurses and providers occurred 33% of the time; 18% believed they received sufficient support to follow-up on deficient paperwork. The barriers mentioned were lack of medications (73%), time (67%), and communication with providers (61%). When asked their opinions on potential interventions, 78% of nurses supported web-based applications, 66% community health workers (CHW), and 66% stock albuterol in schools.

CONCLUSIONS

The greatest barriers for CPS nurses with asthma management are time and communication. Potential interventions such as web-based communication applications and CHW in schools were well received.

A Real-World Community Health Worker Care Coordination Model for High-Risk Children

Health care systems across the United States are considering community health worker (CHW) services for high-risk patients, despite limited data on how to build and sustain effective CHW programs. We describe the process of providing CHW services to 5,289 at-risk patients within a state-run health system. The program includes 30 CHWs, six care coordinators, the Director of Care Coordination, the Medical Director, a registered nurse, mental health specialists, and legal specialists. CHWs are organized into geographic and specialized teams. All CHWs receive basic training that includes oral and mental health; some receive additional disease-specific training. CHWs develop individualized care coordination plans with patients. The implementation of these plans involves delivery of a wide range of social service and coordination support. The number of CHW contacts is determined by patient risk. CHWs spend about 60% of their time in an office setting. To deliver the program optimally, we had to develop multiple CHW job categories that allow for CHW specialization. We created new technology systems to manage operations. Field issues resulted in program changes to improve service delivery and ensure safety. Our experience serves as a model for how to integrate CHWs into clinical and community systems.