Margaret O'Neill

Ways to Identify Children with Medical Complexity and the Importance of Why

Children with medical complexity, although a small fraction of the pediatric population, are important due to their high levels of healthcare spending, unmet healthcare needs, substandard quality of care, and poor health outcomes. 1 Consistent with the Triple Aim, 2 these children are the focus of clinical, research, and policy initiatives seeking to: (1) improve their healthcare experience and quality of care; (2) improve outcomes (for themselves and their families); and (3) reduce the future healthcare costs that they might accrue. 3-8 Clinics, hospitals, states, and countries throughout the world are reforming the health system to optimize its performance for children with medical complexity. 9,10 Although the act of recognizing that a particular child is medically complex may seem straightforward at the individual level, identifying children with medical complexity at a population level is not straightforward. At the individual level, recognizing medical complexity is a subjective distinction, 11 drawing on a person’s experiences and perceptions of viewing a child as being medically complex. 12 When scaled up to population-level, 3 challenges emerge. First, the construct of medical complexity is regarded differently among parents, clinicians, researchers, and others. Second, individual-level details about the child that are evident or discoverable in a one-on-one, in-person encounter (eg, an outpatient clinic visit) are often not readily available in population-level data sources. Third, in contrast to their adult counterparts, children with medical complexity have a heterogeneous array of rare health problems without a select few that dominate in prevalence and impact. With these caveats in mind, we review existing techniques and tools that can be used to identify children with medical complexity from a variety of health data sources, including administrative billing data and parent- or providerreported survey. We organize our review with Cohen et al children with medical complexity definitional framework of interacting characteristics, including complex chronic health problems, substantial healthcare needs, severe functional

Two-year mortality, complications, and healthcare use in children with medicaid following tracheostomy

To assess patient characteristics associated with adverse outcomes in the first 2 years following tracheostomy, and to report healthcare utilization and cost of caring for these children.

Trends in Health Care Spending for Children in Medicaid With High Resource Use.

OBJECTIVES: To assess characteristics associated with health care spending trends among child high resource users in Medicaid. METHODS: This retrospective analysis included 48 743 children ages 1 to 18 years continuously enrolled from 2009–2013 in 10 state Medicaid programs (Truven MarketScan Medicaid Database) also in the top 5% of all health care spending in 2010. Using multivariable regression, associations were assessed between baseline demographic, clinical, and health services characteristics (using 2009–2010 data) with subsequent health care spending (ie, transiently, intermittently, persistently high) from 2011–2013. RESULTS: High spending from 2011–2013 was transient for 54.2%, persistent for 32.9%, and intermittent for 12.9%. Regarding demographic characteristics, the highest likelihood of persistent versus transient spending occurred in children aged 13 to 18 years versus 1 to 2 years in 2010 (odds ratio [OR], 3.0 [95% confidence interval (CI), 2.7–3.4]). Regarding clinical characteristics, the highest likelihoods were in children with ≥6 chronic conditions (OR, 4.8 [95% CI, 3.5–6.6]), a respiratory complex chronic condition (OR, 2.5 [95% CI, 2.2–2.8]), or a neuromuscular complex chronic condition (OR, 2.3 [95% CI, 2.2–2.5]). Hospitalization and emergency department (ED) use in 2010 were associated with a decreased likelihood of persistent spending in 2011–2013 (hospitalization OR, 0.7 [95% CI, 0.7–0.7]); ED OR, 0.8 [95% CI, 0.8–0.8]). CONCLUSIONS: Most children with high spending in Medicaid are without persistently high spending in subsequent years. Adolescent age, multiple chronic conditions, and certain complex chronic conditions increased the likelihood of persistently high spending; hospital and ED use decreased it. These data may help inform the development of new models of care and financing to optimize health and save resources in children with high resource use.

Nursing-led Home Visits Post-hospitalization for Children with Medical Complexity

Purpose Hospital discharge for children with medical complexity (CMC) can be challenging for families. Home visits could potentially benefit CMC and their families after leaving the hospital. We assessed the utility of post‐discharge home visits to identify and address health problems for recently hospitalized CMC. Design and Methods A prospective study of 36 CMC admitted to a childrens hospital from 4/15/2015 to 4/14/2016 identified with a possible high risk of hospital readmission and offered a post‐discharge home visit within 72 h of discharge. The visit was staffed by a hospital nurse familiar with the childs admission. The home visit goals were to reinforce education of the discharge plan, assess the childs home environment, and identify and address any problems or issues that emerged post‐discharge. Results The childrens median age was 6 years [interquartile range (IQR) 2–18]. The median distance from hospital to their home was 38 miles (IQR 8–78). All (n = 36) children had multiple chronic conditions; 89% (n = 32) were assisted with medical technology. The nurse identified and helped with a post‐discharge problem during every (n = 36) visit. Of the 147 problems identified, 26.5% (n = 39) pertained to social/family issues (e.g., financial instability), 23.8% (n = 35) medications (e.g., wrong dose), 20.4% (n = 30) durable medical equipment (e.g., insufficient supply or faulty function), 20.4% (n = 30) childs home environment (e.g., unsafe sleeping arrangement), and 8.8% (n = 13) childs health (e.g., unresolved health problem). Conclusions Home visits helped identify and address post‐discharge issues that occurred for discharged CMC. Practical Implications Hospitals should consider home visits when optimizing discharge care for CMC. HighlightsAn inpatient nurse visited children with medical complexity at home post‐discharge.Nurse identified and assisted with post‐discharge problems for every visit.Most visits identified 3 or more post‐discharge problems.Social/family, medication, and equipment issues were the most common problems.Families and healthcare providers perceived value in the home visit.

Issues Identified by Postdischarge Contact after Pediatric Hospitalization: A Multisite Study

BACKGROUND Many hospitals are considering contacting hospitalized patients soon after discharge to help with issues that arise. OBJECTIVES To (1) describe the prevalence of contact-identified postdischarge issues (PDI) and (2) assess characteristics of children with the highest likelihood of having a PDI. DESIGN, SETTING, AND PATIENTS A retrospective analysis of hospital-initiated follow-up contact for 12,986 children discharged from January 2012 to July 2015 from 4 US children’s hospitals. Contact was made within 14 days of discharge by hospital staff via telephone call, text message, or e-mail. Standardized questions were asked about issues with medications, appointments, and other PDIs. For each hospital, patient characteristics were compared with the likelihood of PDI by using logistic regression. RESULTS Median (interquartile range) age of children at admission was 4.0 years (0a 11); 59.9% were non-Hispanic white, and 51.0% used Medicaid. The most common reasons for admission were bronchiolitis (6.3%), pneumonia (6.2%), asthma (5.1%), and seizure (4.9%). Twenty-five percent of hospitalized children (n = 3263) reported a PDI at contact (hospital range: 16.0%–62.8%). Most (76.3%) PDIs were related to follow-up appointments (eg, difficulty getting one); 20.8% of PDIs were related to medications (eg, problems filling a prescription). Patient characteristics associated with the likelihood of PDI varied across hospitals. Older age (age 10–18 years vs <1 year) was significantly (P < .001) associated with an increased likelihood of PDI in 3 of 4 hospitals. CONCLUSIONS PDIs were identified often through hospital-initiated follow-up contact. Most PDIs were related to appointments. Hospitals caring for children may find this information useful as they strive to optimize their processes for follow-up contact after discharge.