With an overall aim to inform sustainable change in health care delivery through new payment models supporting better care, smarter spending and healthier children with medical complexity, the CARE Award set out to:
- Decrease the impact of chronic illness on families
- Enhance patient experience of care and care coordination
- Provide care closer to home and at lower cost
- Create payment models that support high-quality care and rewards savings
- Decrease utilization of health services
Defining three stages of implementation for analysis context
|Pre-Enrollment Q3 2013 - Q1 2015
||Ramp-Up Q2 2015 – Q1 2016
||Full Implementation Q2 2016 - Q1 2017
Beginning implementation of change concepts
- Create patient registry
- Form dynamic care teams
|Reached 90% enrollment
Change concept implementation
Mixture of children with and without change concept implementation
- 100% registries
- 88% Dynamic care teams
- 57% Access plans
- 54% Care plans
|Reached 100% enrollment Q4 2016
Full implementation of change concepts
The CARE Award chose spending and utilization outcome goals taking into account an October 2013 study of the medically complex pediatric population by the firm Dobson DaVanzo. Based on implementation of a new care model, the study projected a three-year reduction in spending by 6.8 percent, a decrease in inpatient days by 40 percent and a reduction in emergency department (ED) visits by 10 percent.
The CARE Award change concepts were designed to decrease the number of inpatient days by either preventing inpatient admissions or shortening length of stay, and ED utilization, ultimately reducing the overall spend in a three-year window.
It’s important to understand the data sources – provided by eight states including the District of Columbia – and the magnitude of the effort to collect and standardize Medicaid claims data. Claims data was collected on the enrolled children for the three years prior to the start of the project and over the three years of the project. The statistical analysis was applied to a cohort of 3200 children with consistent claims submission 12 months prior and 12 months post the complete implementation of the change concepts. From these claims, teams assessed utilization and spending across the continuum of care including inpatient admissions and total inpatient days, ED discharges, other outpatient services and outpatient pharmacy.
||3-year Aggregate Goal
||12 mos.; 8 hospitals (Preliminary) Q2 2016-Q1 2017
|Decrease inpatient days
|Decrease ED discharges
Spending and utilization
This 12-month analysis observed a 32 percent reduction in patient days, a 26 percent reduction in ED discharges and a 2.6 percent reduction in total spend.
An important aspect of the CARE Award is optimizing health care utilization while simultaneously reducing overall spend. The project’s results show success in all three target categories.
Understanding changes in utilization during the CARE Award provides better context for changes observed in total standardized spend during the CARE Award.
|Estimated Cost Before Transformation
|Observed Cost (Standardized)
|Estimated Gross Savings
|Percent Reduction in Spend
- Spend increased 10.4 percent above expected during ramp-up period as compared to the pre-enrollment period
- Spend decreased 2.6 percent below expected once children were fully enrolled and changes full implemented, with other service lines including pharmacy ultimately impacting the overall reduction estimates.
CARE Award hospitals experienced a 90 percent follow-up from roughly 1,000 baseline family surveys. A statistically significant 1 percent increase in family-related health quality of life was cited. Though the goal was a 10 percent increase, the finding indicates that transformational work focused on utilization and spend can be done without creating a greater burden on families, and may reduce caregiver stress over time.
With a staged implementation of change concepts, best practices and successes spread rapidly across CARE Award teams. As a result, care transformation goals were met or exceeded. Highlights include:
CARE Change Concepts Defined
Care transformation in the CARE Award was built on a set of closely related change concepts designed to be developed jointly with families and providers.
- Each CARE site will have a patient registry
Registries are essential tools for population assessment and management, and quality improvement, both within individual practices and across the continuum of care.
- Every child/family will have a dynamic care team (DCT)
Care of children with complex needs requires an effective, informed and coordinated team. The family drives the composition of the DCT and is a critical partner to other members of the team. DCT membership is representative of the care continuum that includes health care, and community and educational, providers. DCT members recognize each other by name and role, and have effective systems for timely communication among team members.
- Every family will have an access plan containing three components:
1. An after-hours access plan that describes how and when to contact the appropriate clinical provider for health care issues. Every patient and family needs to know who to contact and how to contact them to access the right provider for the right care at all times. A provider must be available 24/7. The access plan should include a listing of all DCT members with contact information and preferred method of contact to expedite access to care.
2. A contingency plan that contains instructions for parent action when the child experiences a change in condition. It describes how and when to contact the appropriate clinical provider for health care issues. These plans are developed from scenarios suggested by families that are likely to result in their child going to the ED. The contingency plan should contain actions to prevent an acute exacerbation, actions if an exacerbation occurs, and what to do if the child does not improve, e.g. when to call 911 or take the child to the ED. It would also outline the accommodations needed for other children in the house, notification of family members, etc.
3. An emergency care plan that provides essential information for emergency responders or ED personnel who are not familiar with the child to expedite effective treatment and communication with the child’s medical home/subspecialty providers. This includes a brief medical history and description of child’s baseline condition, current medications, common presenting problems with suggested diagnostic studies and/or treatment, procedures to avoid, important family preferences, a list of the child’s physicians/their contact information and an advanced directive form.
- Each family will have a care plan based on patient/family goals developed via a shared process between clinicians and child/family
There is a standardized approach (including standardized documents) to care planning used with every child and family. Goals are developed from the assessment of family needs and assets for care planning. Providers and the child/family have the same understanding of roles and acknowledge the same patient goals. Care plan includes action steps to assist child/family attainment of goals. Families and providers across the care continuum have access to the care plan.
- The first patient was enrolled in May 2015, with the enrollment goal (8,000 children) reached by November 2016
- Change concepts were fully implemented by May 2016
- A total of 51 quality improvement (QI) teams were engaged, encompassing more than 265 people
- 42 primary care sites were engaged to provide care coordination services
- Implementation goals were broadly exceeded in the last year
- Process measures met or exceeded targets for three key change concepts – dynamic care teams, access plans and care plans
- Teams developed sustainability plans in the three months following the end of the CARE Award period of care transformation implementation, September- November 2017
There are many anticipated questions that will be considered and addressed by the CARE Award research group in the coming months.
Any payment model is a positive step forward in collaborating with payers; the CARE Award demonstrated that new payment models can drive changes to the care delivery system. There are a number of sustainable alternative payment models with payers that children’s hospitals may consider. Five of the 10 participating hospitals were successful at executing new payment models that support care transformation.