As a pediatrician, I have one of the best jobs in health care: keeping children healthy. It’s also a tremendous responsibility. Children are influenced by many factors beyond their control, making the task of guiding their health that much more important. It’s even more critical when we consider that the health of the child predicts the health of the adult and the ability to grow into a functioning, self-supporting citizen.

As we mold our health care system along the precepts of accountable care, perhaps the single most important goal we can have is ensuring the health of the next generation. At Atrius Health, we have adapted the tools of accountable health care — population management, predictive analytics, and a team approach — to set our young patients on a path to lifetime health. The pediatric medical home incorporates population health tools like predictive analytics to find and head off patients at risk of admissions and ER utilization, and to identify potential over-utilizers of inappropriate care before patterns develop.  A closed loop system of coordinated care focuses on children with complex or chronic conditions to keep them on the road to health.

This blog describes the journey to create the pediatric medical home, refine it through implementation and evaluation, and to measure results.

Atrius Health provides care for 125,000 pediatric patients at 18 different sites. Their care is covered by both commercial and government payors. More than fifty percent of patients at Atrius Health are included in at-risk arrangements, where a capitated amount per patient must be leveraged to provide all health care and to achieve positive outcomes.

The vision of the pediatrics medical home was to create a place for all children where health care services and resources are easily available, family centered, compassionate and culturally sensitive.

The goals of this program are threefold: 

•  Assure all indicated  preventive services are delivered including developmental screening and supporting healthy families
• Identify, treat and coordinate care for chronic illnesses
• Decrease the reliance on ERs and other acute care facilities to provide care.

Fortunately, a strong foundation for the program was already in place: strong leadership, compassionate clinicians, data management capabilities, and a high functioning electronic medical record. To complete the medical home, the following features and functions were added:

•  A new care facilitator role
•  A “medically complex patient” registry with a priority patient designation
• Patient-Family Advisory councils
• Community resource connections

Patients were evaluated and organized into three categories

• Healthy children requiring preventive care
• Children with chronic conditions like behavioral diagnoses, asthma, obesity, diabetes, social risk factors, and adverse childhood events
• Children with complex needs such as neurodevelopmental issues like cerebral palsy, autism, behavioral psychiatric conditions, hematology diagnosis like sickle cell and hemophilia, cancers, dependence on medical technology, multiple chronic conditions, social risk factors and adverse childhood events

This classification correlated with those patients whose care was the most costly. While only .5 percent of children were in the complex care group, their treatment amounted to 25% of the medical spend for the entire population. Children with chronic conditions constituted 25 percent of the population and 70 percent of the medical spend. In aggregate, these two groups make up 95% of the medical spend for all pediatric patients.

Asthma is one of the most common chronic childhood conditions. Therefore, patients with asthma are a population of particular focus within the medical home. Data in the EHR including utilization, medication compliance and lung function assessment were used to identify and stratify this population. At the same time, clinical and coordination protocols were developed to ensure that the children and their families had consistent oversight, interventions and counseling as needed.

To assure optimal outcomes for our asthma population, care is managed proactively by the primary care team. Children are identified for special handling with a priority diagnosis on the schedule. A nurse reviews their recent asthma activity prior to their well visit. At the appointment, they receive a subjective assessment of their symptoms (the asthma control test), and annual spirometry to provide objective lung function data, consistent with evidence-based practice. A color-coded Asthma Action plan is then updated to provide parental and patient education and self-management guidance.

Patients are identified as “high risk” based on a combination of low scores on the asthma control test, obstruction on pulmonary function testing, two or more steroid boluses, five or more albuterol refills, an ER visit or hospital admission, and low asthma medication ratio. These high risk patients receive additional scrutiny with a monthly review through the asthma registry and with care facilitators and nurses supporting relationships and transitions.

A similar model exists for patients with medical or psychosocial complexity. These patients are supported by our Care Facilitators for assistance with navigation of the medical neighborhood including warm handoffs to specialists, support with social needs and connections with community resources and government agencies. The Care Facilitators also work with our Nurse Case Managers to prepare for roster review sessions with the primary care team focused on identifying and addressing our patients’ goals and barriers to achieving optimal care. When appropriate for very high resource utilizers, we have also scheduled inter-institutional roster reviews between primary care and specialists.

How does it all work in real life? Here’s an example of a composite case.

Running to the ER for treatment of her children’s asthma is standard operating procedure for Keisha (not her real name); in fact, the family shows up there at least once a month. A single mother, she struggles to parent two young children with sporadic employment and inconsistent housing.

Keisha’s primary care doctor refers her to the care facilitator, who met with the family in the office that same day. The care facilitator establishes herself as a resource for Keisha and together they discussed the barriers to keeping the kids compliant with their medication and asthma routine. The care facilitator also educates Keisha about 24/7 call-in resources for help and weekend urgent care hours, as well as the option of same day appointments during office hours so that she no longer has to rely on the ER for care.

Because of Keisha’s sporadic schedule, they were able to work out a system where the school nurse at her older child’s school could administer his medication so that he could stay on a consistent course of treatment. And they identified Keisha’s needs for day care, food stamps and to earn her GED and how the care facilitator could help her toward these goals.

Keisha’s ER visits are replaced by same day visits with her Atrius doctors or at night, with attention from the evening call in program.   With her older son’s medication monitored by the nurse at school, he actually has not needed any addition office visits other than regular oversight. Keisha is working on stabilizing her younger son’s condition with stricter adherence to his regimen and support from the care facilitator. She’s started working towards her GED, can provide better nutrition for the family with food stamps, and is working more regular hours now that she has access to daycare for her youngest.

The medical home approach to children with asthma was initiated in 2012, giving time to measure and monitor its results in resource utilization and in cost. Over a six year period of time:

• The asthma ED visits per 1,000 dropped 35% and admissions declined 37%, a strong indicator of the improved health outcomes
•  The costs for ED utilization for asthma declined 9% PMPM (Per Member Per Month) and admissions costs PMPM declined 37%.

With the patient-centered approach in the medical home, children are experiencing better health, more consistent attendance in school, and help with social determinants of health care for both themselves and their families.