PROJECT NAME:
An Enhanced Medical Home Providing
Comprehensive Care (CC) to High-Risk Chronically Ill (CI) Children: A
Randomized Trial (RCT)
Institution: University of Texas- Houston ( UTH) Health science center
Primary Author:
Ricardo A. Mosquera, MD
Secondary Author: Jon E. Tyson, MD
Project Category: Patient Centered Care
Overview:
Despite their presumed benefits, medical homes have not been shown in a RCT 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 rigorous RCT (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
population
Children
with
chronic
illness &
>50%
risk of
hospital
admit
per yr
Resource
Inputs
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
Activities
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*
Outputs
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
Short-term
Outcomes
Reduced
serious
illness
Reduced
total and
Medicaid
&CHIP
costs for
care
N, % eligible with
>1ED visit; Mean (SD)
ED visits
Reduced
disparities
in care &
outcome
(serious
illness)
Care for chronic illnesses
from specialists in our
clinic or whenever
feasible on same day in
another clinic in same
building on same day*
N & % eligible with
serious illness
Reduced
ED visits
N & % eligible
hospitalized; total
hospital admits & d
Reduced
hospital
and PICU
admits & d
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)
N and % eligible
admitted to PICU; total
PICU admits & d
Ongoing refinement of
guidelines for treating
common disorders
Total costs (out- &
inpatient) & :bottom
line” from perspective
of health care system,
Medicaid &CHIP,
hospitals, & Med.
school
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
Mean (SD) clinic visits
N and % of deaths
N and % parent(s)
very satisfied with care
Maintenance of
process & outcome
measures in last 6 mo.
Development of new
reimbursement model
with payments
supporting costs of CC
N of well trained PNPs
& MDs; N giving CC
Increased
parent
satisfaction
CC
sustained
after use of
new
reimbursement
model
Increased
CC work
force
Increased
knowledge
to
establish,
sustain, &
disseminate CC
Longterm
outcomes
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
reimburse
ment
models
Advanced
methods
to disseminate
better
methods
to improve
health
care
Results
Baseline risk factors are similar in CC (n=89) vs UC (n=83) groups. All results to
date favor CC vs UC: 67 vs 118 ED visits; 57 vs 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) = $7,512 vs $26,664
Interim Results after 1 year
Usual
Care
n= 80
Comprehensive
care
n=82
Children with serious
illness (Primary
outcome)
ED visits
16
8
100
62
Hospital admissions
102
54
PICU admissions
17
5
Mortality
3
0
Costs per patient/year
$26,400
$16,320
Usual care
Conclusions
Comprehensive care
This RCT strongly suggests clinical benefits and cost-effectiveness from an
enhanced medical home for chronically ill children