Overview:
Despite their presumed benefits, medical homes have not been shown in aRCT or meta-analysis to be effective or cost saving in reducing major adverse outcomes among chronically ill children. We are conducting a randomized control trial in the high risk children’s clinic at the UTH. Comprehensive care is given in a medical home by a team of experienced caregivers in the department of pediatrics
Aim Statement:
To conduct a rigorousRCT (funded partly by TX Health & Human Services) to assess whether an enhanced medical home providing comprehensive care is cost effective in preventing serious illness (death, pediatric ICU admission, or hospital stay >7d) among chronically ill children. Comprehensive care includes care for acute & chronic problems from a team of experienced caregivers available in person or by phone 24/7.
Measures of Success:
Design/Methods: Since March, 2011,172 CI children 18 yrs old with high medical services (e.g., 3 hospitalizations, &/or 1 ICU stay in the past yr) and 50% estimated risk of hospitalization in the next yr have been randomized to CC or usual care (UC) in our center. CC is modeled after our cost effective CC program for high-risk infants (JAMA, 2000), given by 2 nurse practitioners & 2 pediatricians who know all patients, and includes primary & specialty care & social services. Acute illnesses presenting before 5:00 PM are seen the same week day; those on the weekend, on Monday AM. Parents have our on-call provider's cell phone number; calls are recorded & a sample reviewed.UC includes care from the daily pediatric clinic, specialty clinics, the twice weekly clinic for chronically ill children, & the pediatric ED; parents can call the on-call resident. We use parent reports, hospital & ED logs, and Medicaid records to identify all services & costs. A healthcare economist assesses costs using hospital cost/charge ratios. To maximize the likelihood that positive results will alter clinical practice, our stopping rules are based on showing cost effectiveness (improved outcomes with similar costs, reduced costs with similar outcomes, or both) in yearly interim analysis with complete cost data.
Target popula-tion / Resource
Inputs / Activities / Outputs / Short-term
Outcomes / Long-term outcomes
Children with chronic illness & 50% risk of hospital admit per yr / Project director’s experience, skills in developing, assessing CC programs,
Training
dedication, experience & skills of MDs & PNPs in providing CC past yr
Expertise of health economists
Support of MH system
Patient treatment revenues
Funding, support from UT Houston & Tx HHS
Funding from CMS Innovation Challenge / CC from highly experienced caregivers of broad ethnic background available in clinic 40 hrs /wk & 24/7 by cell phone*
Social services,* well child care, immunizations; anticipatory guidance
Acute care visits on same day (on next wkday AM for calls at night or weekends)*.For ED or hospital admits, staff talk with responsible MD(s) & appoint timely clinic visit*
Care for chronic illnesses from specialists in our clinic or whenever feasible on same day in another clinic in same building on same day*
Data collection: baseline (demographic & clinical at enrollment); process measures (e.g. clinic visits; phone calls during and after hours); & outcome measures (e.g. serious illness; ED visits; hospital admits & days; PICU admits & days; deaths; satisfaction, costs (see text)
Ongoing refinement of guidelines for treating common disorders
Refinement of care based on active input & involvement of Parent Advisory Group*
Recording & review of calls, review of care before hospitalizations, other QI measures in text;
Training of PNPs & MDs / N & % of eligible children enrolled in CC
N & % of eligible still receiving CC at defined intervals after enrolment
Mean (SD) calls to CC staff during day, at night, and on weekend
Mean (SD) clinic visits
N, % eligible with 1ED visit; Mean (SD) ED visits
N & % eligible with serious illness
N & % eligible hospitalized; total hospital admits & d
N and % eligible admitted to PICU; total PICU admits & d
N and % of deaths
N and % parent(s) very satisfied with care
Maintenance of process & outcome measures in last 6 mo.
Total costs (out- & inpatient) & :bottom line” from perspective of health care system, Medicaid &CHIP, hospitals, & Med. school
Development of new reimbursement model with payments supporting costs of CC
N of well trained PNPs & MDs; N giving CC / Reduced serious illness
Reduced total and Medicaid &CHIP costs for care
Reduced disparities in care & outcome (serious illness)
Reduced ED visits
Reduced hospital and PICU admits & d
Increased parent satis-faction
CC sustained after use of new reimburse-ment model
Increased CC work force
Increased knowledge to establish, sustain, & dissemi-nate CC / Broad diffusion of CC in U.S. causing:
-reduced national Medicaid,health system costs for target children
:
-improved care and outcomes
-reduced disparities
Advanced methods to improve reimbursement models
Advanced methods to dissem-inate better methods to improve health care
Results
Baseline risk factors are similar in CC (n=89)vsUC (n=83) groups. All results to date favor CCvs UC: 67 vs 118 ED visits; 57vs 112 hospitalizations; 5 vs 20 PICU admits; 8 vs 19 children with serious illness; 1 vs 4 deaths. Estimated total outpatient and inpatient costs/child/yr available only through 1st 7 mo. (147 patients) = $7,512vs $26,664
Conclusions
This RCT strongly suggests clinical benefits and cost-effectiveness from an enhanced medical home for chronically ill children