Lessons Learned

Ten hospitals set out to improve care and reduce costs for children with medical complexity (CMC) by engaging all stakeholders in the redesign of care delivery and payment models. Despite encountering challenges during the activation period, participants continued to progress toward the project's goals. When the CARE Award concluded in June 2018, the effort had uncovered effective interventions and multiple insights that can be used by other health care organizations to improve care for CMC. Among the key takeaways:

1. Data is messy

Expertise in data analysis is critical, as well as new solutions for data standardization.

2. Severity affects cost

Payments should reflect the severity level of CMC children’s hospitals care for, which can be much higher compared to national reference data.

3. Size counts

The small size of the CMC population may not lend itself to effectively designing a risk-based model or engaging the payer. Longer-term utilization and spend analyses is necessary for success.

4. One step at a time

Opportunities exist to transform the pediatric delivery system incrementally by leveraging market innovation models, accomplishing symbolic payment model improvement, and evaluating the entire health system design versus only a program development strategy.

5. The essential elements

The costs of an optimal care coordination program for CMC should include dynamic care teams, family support services, care coordination services, and time for primary care physician oversight.

6. Redefine first contact

Primary care physicians provide preventive care and first contact for illnesses. They need support to engage in care transformation, and should be included as active partners in the new care model and payment model designs.

7. The whole picture

Payment model measurement must move beyond cost and utilization to address family well-being and care coordination, which are elements necessary for reducing unnecessary utilization and hospitalizations. Standards are needed for this.

8. Keep an eye on access

Children’s hospitals with established medical homes can close gaps in providing better care for CMC. This is accomplished with close attention to improving family access to avoid acute care visits, timely care plans and explicit patient-stated goals.

9.Family input

As frequent users of health care resources, engaging families of CMC in care redesign provides deeper knowledge on how to transform the delivery system. It’s important to use insights from parent interviews and surveys to reduce their burden of care.

10. Prevention is key

Impacting utilization requires specific preventive interventions for addressing rising risk situations, such as creating access and contingency plans for emergent situations and seasonality issues.