Association of a Targeted Population Health Management Intervention with Hospital Admissions and Bed-Days for Medicaid-Enrolled Children.

2019

e1918306

2019 Dec 02

2574-3805

<p><strong>Importance: </strong>As the proportion of children with Medicaid coverage increases, many pediatric health systems are searching for effective strategies to improve management of this high-risk population and reduce the need for inpatient resources.</p>

<p><strong>Objective: </strong>To estimate the association of a targeted population health management intervention for children eligible for Medicaid with changes in monthly hospital admissions and bed-days.</p>

<p><strong>Design, Setting, and Participants: </strong>This quality improvement study, using difference-in-differences analysis, deployed integrated team interventions in an academic pediatric health system with 31 in-network primary care practices among children enrolled in Medicaid who received care at the health system's hospital and primary care practices. Data were collected from January 2014 to June 2017. Data analysis took place from January 2018 to June 2019.</p>

<p><strong>Exposures: </strong>Targeted deployment of integrated team interventions, each including electronic medical record registry development and reporting alongside a common longitudinal quality improvement framework to distribute workflow among interdisciplinary clinicians and community health workers.</p>

<p><strong>Main Outcomes and Measures: </strong>Trends in monthly inpatient admissions and bed-days (per 1000 beneficiaries) during the preimplementation period (ie, January 1, 2014, to June 30, 2015) compared with the postimplementation period (ie, July 1, 2015, to June 30, 2017).</p>

<p><strong>Results: </strong>Of 25 460 children admitted to the hospital's health system during the study period, 8418 (33.1%) (3869 [46.0%] girls; 3308 [39.3%] aged ≤1 year; 5694 [67.6%] black) were from in-network practices, and 17 042 (67.9%) (7779 [45.7%] girls; 6031 [35.4%] aged ≤1 year; 7167 [41.2%] black) were from out-of-network practices. Compared with out-of-network patients, in-network patients experienced a decrease of 0.39 (95% CI, 0.10-0.68) monthly admissions per 1000 beneficiaries (P = .009) and 2.20 (95% CI, 0.90-3.49) monthly bed-days per 1000 beneficiaries (P = .001). Accounting for disproportionate growth in the number of children with medical complexity who were in-network to the health system, this group experienced a monthly decrease in admissions of 0.54 (95% CI, 0.13-0.95) per 1000 beneficiaries (P = .01) and in bed-days of 3.25 (95% CI, 1.46-5.04) per 1000 beneficiaries (P = .001) compared with out-of-network patients. Annualized, these differences could translate to a reduction of 3600 bed-days for a population of 93 000 children eligible for Medicaid.</p>

<p><strong>Conclusions and Relevance: </strong>In this quality improvement study, a population health management approach providing targeted integrated care team interventions for children with medical and social complexity being cared for in a primary care network was associated with a reduction in service utilization compared with an out-of-network comparison group. Standardizing the work of care teams with quality improvement methods and integrated information technology tools may provide a scalable strategy for health systems to mitigate risk from a growing population of children who are eligible for Medicaid.</p>

10.1001/jamanetworkopen.2019.18306

JAMA Netw Open

31880799

Consumerism, Innovation, and the Future of Pediatric Primary Care.

2018

2018 Jul 30

2168-6211

<p>Netflix was founded in 1997 to allow consumers access to video content from home. By 2000, focused on second-tier films, Netflix developed a subscription service featuring unlimited, fixed-price rentals. That same year, Netflix approached Blockbuster, the dominant movie rental company at that time, first offering to become Blockbuster’s online retail arm and then to sell itself for $50 million. Both offers were declined. In 2008, Blockbuster declared that Netflix is “not even on the radar screen in terms of competition.”<sup><a class="ref-link section-jump-link" data-tab-toggle=".tab-nav-references" href="https://jamanetwork.com/journals/jamapediatrics/article-abstract/268878…; Failing to recognize Netflix’s ability to satisfy the customer, Blockbuster filed for bankruptcy in 2010. In contrast, Netflix, now with more than 100 million subscribers, achieved dominance by betting on emerging technology for streaming video. What might this example teach us about the future of a very different service, pediatric primary care?</p>

10.1001/jamapediatrics.2018.1501

JAMA Pediatr

30073320

Pediatric integrated delivery system's experience with pandemic influenza A (H1N1).

2012

635-44

2012 Oct

1936-2692

<p><strong>OBJECTIVE: </strong>To describe 1 pediatric integrated delivery system's experience with the influenza A (H1N1) pandemic in 2009 to illustrate the benefits of coordination, scale, scope, and flexibility in handling large volumes of patients in many locations.</p>

<p><strong>METHODS: </strong>Through multidisciplinary planning across a large, multisite pediatric delivery system, an effective 3-tier plan was developed to handle anticipated increased volumes associated with the fall 2009 influenza pandemic in the Philadelphia region.</p>

<p><strong>RESULTS: </strong>Patient demand for services increased to record-setting levels, particularly for emergency department visits and phone calls. The 3-tier plan of response allowed for graded and appropriate response to volumes that more than doubled in many locations. Measured by wait times and leftwithout- being-seen rates, the system appeared to match capacity to demand effectively. Lessons learned in terms of successes and challenges are useful for future planning.</p>

<p><strong>CONCLUSIONS: </strong>The experience of 1 pediatric delivery system in handling increased volume due to pandemic influenza may hold lessons for other organizations and for policy makers seeking to improve the preparedness, quality, and value of healthcare. These experiences do not imply the need for vertical integration with ownership, but do support tight coordination, communication, integration, and alignment in any management structure.</p>

Am J Manag Care

23145807

Impact of clinical alerts within an electronic health record on routine childhood immunization in an urban pediatric population.

2007

707-14

10/2007

1098-4275

<p><strong>OBJECTIVES: </strong>The objective of this study was to test the hypothesis that clinical alerts for routine pediatric vaccinations within an electronic health record would reduce missed opportunities for vaccination and improve immunization rates for young children in an inner-city population.</p>

<p><strong>METHODS: </strong>A 1-year intervention study (September 1, 2004, to August 31, 2005) with historical controls was conducted in 4 urban primary care centers affiliated with an academic medical center. All children who were younger than 24 months were enrolled. Electronic health record-based clinical reminders for routine childhood vaccinations were programmed to appear prominently at every patient encounter with vaccines due. The main outcome measures were rates of captured immunization opportunities and overall immunization rates at 24 months of age.</p>

<p><strong>RESULTS: </strong>Immunization alerts appeared at 15,928 visits during the intervention. Alert implementation was associated with increases in captured immunization opportunities from 78.2% to 90.3% at well visits and from 11.3% to 32.0% at sick visits. Adjusted up-to-date immunization rates at 24 months of age increased from 81.7% to 90.1% from the control to intervention period. Children in the intervention group also became up-to-date earlier than control patients. Patient characteristics were stable throughout the study.</p>

<p><strong>CONCLUSIONS: </strong>An electronic health record-based clinical alert intervention was associated with increases in captured opportunities for vaccination at both sick and well visits and significant improvements in immunization rates at 2 years of age. As electronic health records become more common in medical practice, such systems may transform immunization delivery to children.</p>

10.1542/peds.2007-0257

Pediatrics

17908756