Complex Care Hospital Use and Postdischarge Coaching: A Randomized Controlled Trial.

OBJECTIVES: We sought to examine the effect of a caregiver coaching intervention, Plans for Action and Care Transitions (PACT), on hospital use among children with medical complexity (CMC) within a complex care medical home at an urban tertiary medical center. METHODS: PACT was an 18-month caregiver coaching intervention designed to influence key drivers of hospitalizations: (1) recognizing critical symptoms and conducting crisis plans and (2) supporting comprehensive hospital transitions. Usual care was within a complex care medical home. Primary outcomes included hospitalizations and 30-day readmissions. Secondary outcomes included total charges and mortality. Intervention effects were examined with bivariate and multivariate analyses. RESULTS: From December 2014 to September 2016, 147 English- and Spanish-speaking CMC <18 years old and their caregivers were randomly assigned to PACT (n = 77) or usual care (n = 70). Most patients were Hispanic, Spanish-speaking, and publicly insured. Although in unadjusted intent-to-treat analyses, only charges were significantly reduced, both hospitalizations and charges were lower in adjusted analyses. Hospitalization rates (per 100 child-years) were 81 for PACT vs 101 for usual care (adjusted incident rate ratio: 0.61 [95% confidence interval 0.38-0.97]). Adjusted mean charges per patient were $14 206 lower in PACT. There were 0 deaths in PACT vs 4 in usual care (log-rank P = .04). CONCLUSIONS: Among CMC within a complex care program, a health coaching intervention designed to identify, prevent, and manage patient-specific crises and postdischarge transitions appears to lower hospitalizations and charges. Future research should confirm findings in broader populations and care models.

Strategies to Reduce Hospitalizations of Children With Medical Complexity Through Complex Care: Expert Perspectives.

OBJECTIVE: Interventions to reduce disproportionate hospital use among children with medical complexity (CMC) are needed. We conducted a rigorous, structured process to develop intervention strategies aiming to reduce hospitalizations within a complex care program population. METHODS: A complex care medical home program used 1) semistructured interviews of caregivers of CMC experiencing acute, unscheduled hospitalizations and 2) literature review on preventing hospitalizations among CMC to develop key drivers for lowering hospital utilization and link them with intervention strategies. Using an adapted version of the RAND/UCLA Appropriateness Method, an expert panel rated each model for effectiveness at impacting each key driver and ultimately reducing hospitalizations. The complex care program applied these findings to select a final set of feasible intervention strategies for implementation. RESULTS: Intervention strategies focused on expanding access to familiar providers, enhancing general or technical caregiver knowledge and skill, creating specific and proactive crisis or contingency plans, and improving transitions between hospital and home. Activities aimed to facilitate family-centered, flexible implementation and consideration of all of the child's environments, including school and while traveling. Tailored activities and special attention to the highest utilizing subset of CMC were also critical for these interventions. CONCLUSIONS: A set of intervention strategies to reduce hospitalizations among CMC, informed by key drivers, can be created through a structured, reproducible process. Both this process and the results may be relevant to clinical programs and researchers aiming to reduce hospital utilization through the medical home for CMC.

Discharge Handoff Communication and Pediatric Readmissions.

BACKGROUND: Improvement in hospital transitional care has become a major national priority, although the impact on children's postdischarge outcomes is unclear. OBJECTIVE: To characterize common handoff practices between hospital and primary care providers (PCPs), and test the hypothesis that common handoff practices would be associated with fewer unplanned readmissions. DESIGN, SETTING, AND PATIENTS: This prospective cohort study enrolled randomly selected pediatric patients during an acute hospitalization at a tertiary children's hospital in 2012-2014. MEASUREMENTS: Primary care and patient data were abstracted from administrative, caregiver, and PCP questionnaires on admission through 30 days postdischarge. The primary outcome was 30-day unplanned readmission to any hospital. Logistic regression assessed relationships between readmissions and 11 handoff communication practices. RESULTS: We enrolled 701 children, from which 685 identified PCPs. Complete data were collected from 84% of PCPs. Communication practices varied widely--verbal handoffs occurred rarely (10.7%); PCP notification of admission occurred for 50.8%. Caregiver experience scores, using an adapted Care Transitions Measure-3, were high but were unrelated to readmissions. Thirty-day unplanned readmissions to any hospital were unrelated to most handoff practices. Having PCP follow-up appointments scheduled prior to discharge was associated with more readmissions (adjusted odds ratio, 2.20; 95% confidence interval, 1.08-4.46). CONCLUSION: Despite their presumed value, common handoff practices between hospital providers and PCPs may not lead to reductions in postdischarge utilization for children. Addressing broader constructs like caregiver self-efficacy or social determinants is likely necessary. Journal of Hospital Medicine 2017;12:29-35.

How Avoidable are Hospitalizations for Children With Medical Complexity? Understanding Parent Perspectives.

OBJECTIVE: Children with medical complexity (CMC) are a small group that utilizes large amounts of health care resources. Although parents are the primary healthcare decision-makers for their children, little is known from their perspective about why CMC are hospitalized. We sought to understand what parents think about factors leading to hospitalization and whether any recent hospitalizations might have been avoidable. METHODS: We conducted qualitative, semistructured interviews with 35 parents of hospitalized CMC who receive care in the Pediatric Medical Home Program, a complex care program at University of California, Los Angeles. Interviews were conducted in English and in Spanish, audio-recorded, transcribed and translated, then coded in ATLAS.ti (Scientific Software Development Gmbh, Berlin, Germany) for qualitative analysis. We sorted qualitative codes into groups with shared concepts, to generate emergent themes. RESULTS: Parents described their experiences leading up to their children's hospitalization, but no one suggested that the hospitalization was potentially avoidable. Most parents perceived their children as having higher susceptibility because of underlying conditions, perceived the symptoms they observed as high-risk, and described seeking emergent care only when they no longer were comfortable at home. Decisions about where to seek care were influenced by health care system factors such as accessibility and continuity of care. Most parents expressed a desire to learn more about their children's conditions and how best to care for them at home. CONCLUSIONS: Parents of CMC believe that hospitalizations are largely unavoidable because of higher susceptibility and higher risk. Increasing parents' self-efficacy in caring for children at home might influence their decisions to seek emergent care.

The Medical Home and Hospital Readmissions.

BACKGROUND AND OBJECTIVE: Despite considerable attention, little is known about the degree to which primary care medical homes influence early postdischarge utilization. We sought to test the hypothesis that patients with medical homes are less likely to have early postdischarge hospital or emergency department (ED) encounters. METHODS: This prospective cohort study enrolled randomly selected patients during an acute hospitalization at a children's hospital during 2012 to 2014. Demographic and clinical data were abstracted from administrative sources and caregiver questionnaires on admission through 30 days postdischarge. Medical home experience was assessed by using Maternal and Child Health Bureau definitions. Primary outcomes were 30-day unplanned readmission and 7-day ED visits to any hospital. Logistic regression explored relationships between outcomes and medical home experiences. RESULTS: We followed 701 patients, 97% with complete data. Thirty-day unplanned readmission and 7-day ED revisit rates were 12.4% and 5.6%, respectively. More than 65% did not have a medical home. In adjusted models, those with medical home component "having a usual source of sick and well care" had fewer readmissions than those without (adjusted odds ratio 0.54, 95% confidence interval 0.30-0.96). Readmissions were higher among those with less parent confidence in avoiding a readmission, subspecialist primary care providers, longer length of index stay, and more hospitalizations in the past year. ED visits were associated with lack of parent confidence but not medical home components. CONCLUSIONS: Lacking a usual source for care was associated with readmissions. Lack of parent confidence was associated with readmissions and ED visits. This information may be used to target interventions or identify high-risk patients before discharge.

Preventing hospitalizations in children with medical complexity: a systematic review.

BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) account for disproportionately high hospital use, and it is unknown if hospitalizations may be prevented. Our objective was to summarize evidence from (1) studies characterizing potentially preventable hospitalizations in CMC and (2) interventions aiming to reduce such hospitalizations. METHODS: Our data sources include Medline, Cochrane Central Register of Controlled Trials, Web of Science, and Cumulative Index to Nursing and Allied Health Literature databases from their originations, and hand search of article bibliographies. Observational studies (n = 13) characterized potentially preventable hospitalizations, and experimental studies (n = 4) evaluated the efficacy of interventions to reduce them. Data were extracted on patient and family characteristics, medical complexity and preventable hospitalization indicators, hospitalization rates, costs, and days. Results of interventions were summarized by their effect on changes in hospital use. RESULTS: Preventable hospitalizations were measured in 3 ways: ambulatory care sensitive conditions, readmissions, or investigator-defined criteria. Postsurgical patients, those with neurologic disorders, and those with medical devices had higher preventable hospitalization rates, as did those with public insurance and nonwhite race/ethnicity. Passive smoke exposure, nonadherence to medications, and lack of follow-up after discharge were additional risks. Hospitalizations for ambulatory care sensitive conditions were less common in more complex patients. Patients receiving home visits, care coordination, chronic care-management, and continuity across settings had fewer preventable hospitalizations. CONCLUSIONS: There were a limited number of published studies. Measures for CMC and preventable hospitalizations were heterogeneous. Risk of bias was moderate due primarily to limited controlled experimental designs. Reductions in hospital use among CMC might be possible. Strategies should target primary drivers of preventable hospitalizations.