Utilization and Spend Across the Continuum

The CARE Award monitored changes in utilization for inpatient days and emergency department (ED) visits, and analyzed each child's spend across the continuum of care to understand the impact of the newly designed clinical care model. Outcomes showed a 32 percent drop in inpatient days, a 26 percent drop in ED discharges and a 2.6 percent decrease in total spend during the final year of the CARE Award, representing a full year of implementation of the new models.

Per year, children enrolled in the CARE Award experienced an average of six days in the hospital, two ED visits, 13 mental health visits, 14 office visits, 16 home health days and 34 prescriptions. Total spending averaged over $50,000 per year.

3M Clinical Risk Group (CRG)

Non-Chronic (CRGs 1, 2) Episodic Chronic (CRGs 3, 4) Lifelong Chronic (CRG 5) Complex Chronic (CRGs 6, 7, 9) Malignancies (CRG 8)
Brief Description Acute conditions that will not last one year Chronic conditions that will last one year and are likely to be episodic in manifestation

Potentially curable with adequate treatment

Not likely to last into adulthood
More severe primary condition in one body system that is more likely to cause significant long-lasting health impairment Significant chronic condition in two or more body systems

or

Progressive or life limiting chronic conditions

or

Conditions requiring a dependency on technology
Malignancies requiring active treatment
Example Conditions Fracture, pneumonia, appendicitis, trauma Asthma, depression, conduct disorders Type 1 diabetes, congenital heart disease A child with diabetes, encephalopathy and chronic pulmonary disease.
Down syndrome, cerebral palsy, cystic fibrosis
Leukemia, bone tumors, brain tumors

*Category 5 is further broken into two subcategories by the Children’s Hospital Association - 5a and 5b. The definition of Medically Complex Children includes 5b - Single Dominant Chronic Disease, such as those with Sickle Cell Disease or Congenital Heart Disease


Impacting the Health Care Spend

Three elements work together to reduce utilization and spend, and decrease the burden of care for the family: a focus on families, family-driven care and emergency planning, the use of care coordinators, and enhanced relationships between primary care physicians, specialty physicians and community services.


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Coordinating Supportive Services

Medical care doesn’t live in isolation; children’s hospitals are only one piece of a support system for a CMC. For Mike Aubin, CEO, Wolfson Children's Hospital in Jacksonville, Florida, the CARE Award was a way to evaluate and organize thinking about how the hospital cared for this complex population from a system of care perspective. "We focused on identifying them early in the process, managing them through the process, and giving them alternatives to make sure that they use the least costly services but get the best care,” he said.

“We tend to be hospital centric sometimes. We had to think about it all very differently with very sick kids.”


Related resources

Poster

Costs and Utilization Vary with Increasing Complexity

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Primary Drivers of Cost for a Specific Population

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Care Spending for a Highly Complex Population

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Outpatient Prescription Spend

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In and Out of Network Spend for a Complex Population

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Poster

Outpatient Prescription Medication Use and Spending

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The CARE Award Results

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CARE Webinar Series

Stabilizing the Cost of Care

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