A Multidisciplinary Home Visiting Program for Children With Medical Complexity.

OBJECTIVES: Given the high needs and costs associated with the care of children with medical complexity (CMC), innovative models of care are needed. Home-visiting care models are effective in subpopulations of pediatrics and medically complex adults, but there is no literature on this model for CMC. We describe the development and outcomes of a multidisciplinary program that provides comprehensive home-based primary care for CMC. METHODS: Medical records from our institution were reviewed for patients enrolled in our program from July 2013 through March 2019. Demographics, clinical characteristics, and health care use were collected. We compared the differences in pre- and postprogram enrollment health care use using Wilcoxon signed rank test. We applied Cox proportional hazard models to examine the association between the time-dependent postenrollment health care use and numbers of home visits. We collected total claims data for a subset of our patients to examine total costs of care. RESULTS: We reviewed data collected from 121 patients. With our findings, we demonstrate that enrollment in our program is associated with reductions in average length of stay. More home visits were associated with decreased emergency department visits and hospitalizations. We also observed in patients with available cost data that total costs of care decreased after enrollment into the program. CONCLUSIONS: Our model has the potential to improve health outcomes and be financially sustainable by providing home-based primary care to CMC.

Inadequate coordination of maternal and infant HIV services detrimentally affects early infant diagnosis outcomes in Lilongwe, Malawi.

OBJECTIVE: To assess the continuity of care and outcome of pediatric HIV prevention, testing, and treatment services, focusing on early infant diagnosis with DNA polymerase chain reaction (PCR). DESIGN: A retrospective observational cohort. METHODS: Maternal HIV antibody, infant HIV DNA PCR test results, and outcome data from HIV-infected infants from the prevention of mother-to-child transmission, early infant diagnosis, and pediatric HIV treatment programs operating in Lilongwe, Malawi, between 2004 and 2008 were collected, merged, and analyzed. RESULTS: Of the 14,669 pregnant women who tested HIV antibody positive, 7875 infants (53.7%) received HIV DNA PCR testing. One thousand eighty-four infants (13.8%) were HIV infected. Three hundred twenty (29.5%) children enrolled into pediatric HIV care, with 202 (63.1%) at the Baylor Center of Excellence. Among these, antiretroviral therapy was initiated on 110 infants (54.5%) whose median age was 9.1 months (interquartile range, 5.4-13.8) and a median of 2.5 months (interquartile range, 1.4-5.2) after HIV clinic registration. Sixty-nine HIV-infected infants (34.2%) died or were lost by December 2008. Initiation of antiretroviral therapy increased the likelihood of survival 7-fold (odds ratio, 7.1; 95% confidence interval, 3.68 to 13.70). CONCLUSIONS: Separate programs for maternal and infant HIV prevention and care services demonstrated high attrition rates of HIV-exposed and HIV-infected infants, elevated levels of mother-to-child transmission, late infant diagnosis, delayed pediatric antiretroviral therapy initiation, and high HIV-infected infant mortality. Antiretroviral therapy increased HIV-infected infant survival, emphasizing the urgent need for improved service coordination and strategies that increase access to infant HIV diagnosis, improve patient retention, and reduce antiretroviral therapy initiation delays.