Novel Interventions in Children's Healthcare
“Bending the curve” refers to the need to shift the trajectory of healthcare spending. The overarching efforts in bending the curve are subsumed under the “triple aim” in healthcare reform: 1) reducing costs, 2) improving care, and 3) improving health. Because 4% of all Medicaid recipients are responsible for upwards of 50% of all Medicaid expenditures, one of the primary targets for bending the curve are the highest utilizers of healthcare resources. When it comes to Medicaid patients, youth with complex medical conditions are responsible for a disproportionate amount of healthcare spending. Most of the healthcare utilization in this population is avoidable and driven by the social determinants of health. Novel Interventions in Children’s Healthcare (NICH) involves the implementation of an intensive behavioral health intervention for youth with complex and chronic medical conditions who are at risk for repeated hospitalizations and who experience challenging social situations. NICH is empirically grounded in three interventions and theoretically grounded in Bronfenbrenner's social ecology model. NICH services, which are 24/7, are provided to children and their families in the communities in which they live, thus addressing the obstacles to health that are not apparent when patients are in clinics and hospitals.
Current approaches in caring for youth with both medical and social complexity are woefully ineffective. In addition, the current fee for service model is not optimal for our most vulnerable youth given that most of the obstacles to improved health are in the social milieu. Thus, to achieve the goals of improved care, healthier youth, and more efficient spending, health care systems must substantively reform their approach with the most vulnerable youth through payment structures that incentivize quality, health outcomes, and “value over volume. In addition, care must involve the coordination and management of all the resources in one's social milieu. Thus, the innovation of NICH is that services are provided to youth and their families in their social milieu offering the requisite resources with an emphasis on behavior change and preventative care, but also provided outside of the fee-for-service model with health insurance payers making NICH highly innovative.
NICH has been recognized as a national and international leader for its work with youth with medical and social vulnerability. NICH received a 2015 Clinical Innovation Award from the Association of American Medical Colleges. NICH has received awards from EPIC for clinical innovation in providing care to a highly vulnerable population. NICH staff have participated as expert panelists for the kick-off meeting of the CHILD-BRIGHT Study being implemented across Canada with a focus on innovative care to youth with disabilities. Dr. Michael A. Harris, the developer of NICH, participated in an invitation-only conference in Washington DC on innovative care for children with medical complexity sponsored by the Lucile Packard Children's Health Foundation (LPCHF). Dr. Harris co-presented during a webinar sponsored by LPCHF on coordinating care for children in families with complex social and health needs with 600 participants. Thus NICH is serving as a leader in program design and implementation.
Initially, this program was a pilot program funded by CSSI funds from Oregon’s largest Medicaid payer. Based on the outcome data from the CSSI grant, we met with Medicaid leadership and negotiated a case-rate for ongoing NICH services to high-risk youth with both medical and social complexity. After sharing our pilot data with other Medicaid medical directors, several other Medicaid programs across Oregon requested contracts for NICH services to their population of youth with medical and social complexity. Payment for NICH uses an Alternative Payment Method given that most services are not billable. Currently, we are serving youth enrolled in 7 of the 16 Coordinate Care Organizations in Oregon and have provided services to over 180 medically and socially complex youth in Oregon, thus the success of NICH has been realized and as it is being disseminated across Oregon and funding has increased significantly from both Medicaid and commercial payers.
NICH is engaged in several dissemination projects with a goal of serving more vulnerable youth outside of Oregon. NICH completed a pilot to youth with developmental disabilities in a partnership with The New York Foundling Charity. The Foundling Charity successfully provided NICH to 40 youth with developmental disabilities with the goal of keeping the youth mainstreamed and avoiding "high-cost" institutionalization. While successfully meeting its goal, NICH is no longer being provided by The Foundling Charity. More recently, NICH is in it's 2nd year of implementation at Stanford/Lucile Packard Children's Hospital to youth with both medical and social vulnerability. In addition, a NICH pilot is in the planning stages at Baylor/Texas Children's Hospital for 45 youth with medical and social vulnerability. Finally, NICH was just awarded a grant from The Helmsley Charitable Trust to do a more comprehensive evaluation of the cost outcomes with the purpose of other institutions implementing NICH.
To date, our data on cost reduction indicates 21% decrease in emergency department admissions, 50% decrease in hospitalizations, 73% decrease in hospital day stays, and decrease in healthcare costs by 50% from the year prior to NICH involvement to the year during and after NICH involvement. The impact on the child health is demonstrated in disease-specific outcomes. For example, patients in NICH with T1D evidence > 1% decrease in HbA1c values. For the patients with nephrotic syndrome and end-stage renal disease, patients are showing significant reductions in phosphorus and potassium. In addition, most patients receiving NICH services who were not candidates for transplant have been listed or successfully transplanted. Outcomes on improvements in care have indicated significant more time spent by providers on patient improvements during clinic visits, a dramatic reduction in no-shows, improvements in communication between the family and healthcare team, as well as many other improvements in care.
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