Inpatient Consultation for High-Risk Chronically Ill Children Receiving Care in an Enhanced Medical Home: a Pilot Quality Improvement Study

Background and Rationale: Comprehensive care (CC) provided in the High-Risk Children's Clinic (HRCC) at The University of Texas Health Science Center at Houston (UTHealth) involves care for acute and chronic conditions from a team of ethnically diverse pediatricians and nurse practitioners who are highly trained and experienced in treating medically complex and fragile children. This clinic serves as a novel medical home where both primary and specialty services are provided in the same place at the same visit. Acute problems presenting before 4 pm are seen the same day or if they occur over the weekend, on Monday morning. All parents have the cell phone number to directly reach 1 of the primary care clinicians at all hours. Multiple measures are used to promote and ensure the highest quality of care such as daily checks of emergency department and hospital logs to ensure prompt follow-up and coordination of care, weekly HRCC provider team meetings to review the care provided before every ED visit and hospitalization, high priority given to minimizing unnecessary ED visits and hospitalizations, and a relatively low patient-to-staff ratio of no greater than 100 (to allow for longer clinic visits, more telephone calls and e-mails, and extensive quality improvement measures).

Comprehensive care undoubtedly increases access to high-quality healthcare for high-risk disadvantaged children. The findings of our previous randomized trial of comprehensive care vs. usual care that were given accelerated publication in JAMA (2014) have attracted national attention as the best evidence to date supporting medical homes to reduce either adverse outcomes or costs (Mosquera et al., 2014). Comprehensive care resulted in major benefits (ED visits, hospital admissions & days, pediatric ICU admissions & days were all reduced by 47-69%) and savings of >$10,000/child/year from the health system perspective. Indeed, the improvements in outcomes and reduction in costs exceed those previously reported in prior studies of medical homes for patients of any age or condition (Mosquera et al., 2014; Homer et al., 2008; Jackson et al., 2013).

Despite these demonstrated benefits, high-risk patients seen in the High-Risk Children's Clinic still experience high rates of morbidity and often require hospitalization for treatment of acute exacerbations of their underlying chronic conditions. In 2015, 100 HRCC patients experienced a total of 175 admissions at Children's Memorial Hermann Hospital (CMHH) for a mean length of stay (LOS) of 7.1 days. As a result, a pilot quality improvement (QI) trial will be conducted to assess the impact of offering inpatient consultation (IC) at CMHH to further optimize coordination and integration of inpatient and outpatient care and reduce total hospital days per child-year.

Inclusion/Exclusion criteria: HRCC patients who require admission to CMHH will be included in the pilot trial. HRCC patients ≥ 18 years of age at study initiation will be excluded from the pilot trial and so will those with a Do-Not-Resuscitate (DNR) order, unrepaired congenital heart disease, active cancer, mitochondrial disorder, or seen in the HRCC clinic solely for compassionate care.

Enrollment period: All eligible HRCC patients who are admitted to CMHH between October 3, 2016 and October 2, 2019 will be enrolled in the pilot trial.