Researchers at the Children’s Hospital of Philadelphia (CHOP) found that among more than 93,000 Medicaid-enrolled children, combining technology solutions with interdisciplinary integrated care teams led to 50 fewer hospital admissions each month and 3,600 fewer bed days for these youth in a year.
CHOP is one of the largest pediatric health systems in the U.S., with more than 500,000 children visiting its facilities each year. It called the study, published in JAMA Network Open, the largest-ever study to measure the impact of population health strategies and tools on hospital outcomes among Medicaid-enrolled children,
The CHOP intervention, implemented over two years, sought to identify high-risk, Medicaid-enrolled children with special healthcare needs and provide solutions that would keep them out of the hospital or reduce their stays if they were admitted. A set of reporting tools in patients' electronic medical record notified clinicians and staff if their patients visited the emergency department or were admitted into the hospital. Then, an integrated care team would connect with these families to help them schedule and prepare for follow-up appointments, assist with locating needed services and answer questions they had about their care. These clinical teams also used tech tools to improve coordination and communication between them.
In a statement describing the study, David Rubin, M.D., director of Population Health Innovation and PolicyLab at CHOP and lead author on the study, noted: "As healthcare systems grow larger, integrated care teams and technology that supports those teams are going to be critically important to ensure we're helping families navigate ever more complex institutions, whether adult or pediatric in nature."
(Founded in 2008, PolicyLab is dedicated to achieving optimal child health and well-being by informing program and policy changes through interdisciplinary research.)
"Fundamentally, what we are talking about is identifying those patients who need the most proactive care, surrounding them with an expert team—from physicians, to nurses, to social workers, to navigators—and then equipping that team with supportive technology,” Rubin continued. “In doing that, we saw that we can deliver the type of care our patients want while providing value and efficiency throughout the whole health care system."
The integrated care teams — composed of physicians, nurses, social workers and community health workers — were more proactive in their engagement with families because they were notified promptly of high-risk events like hospitalizations. For healthy children included in the study, population health reports through the electronic health record in their primary care practice helped ensure timely follow-up from emergency department visits and better compliance with recommended well-child visits and vaccinations. Finally, given that children with multiple prior asthma-related hospitalizations are at highest risk of future asthma-related hospitalizations and emergency department visits, their intervention was customized with a bundle of integrated services. This included personalized bedside education in the hospital, facilitated filling of discharge medications, connection to community health workers/asthma navigators who can facilitate enhanced coordination between inpatient and outpatient care teams, and expedited follow-up with an allergist or pulmonologist.
The researchers attributed the success of this population-level intervention to their ability to deliver services to families within their existing healthcare system, investments to develop strong integrated care teams, alignment of clinical and quality improvement methods and a wide variety of electronic health record tools.
CHOP's Population Health Innovation team—including data analysts, electronic health record experts and quality improvement advisors—partners with departments and divisions across the health system and its specialty and primary care providers to implement and sustain population health management solutions that improve patient experience and health outcomes for the populations they serve.
